Free Neck Pain Report Name * First Name Last Name Phone (###) ### #### Email * How old are you? * <30 years old 31-54 years old >55 years old How long have you had neck pain? * >1 month 1-3 months >3 months Does your neck pain travel anywhere? * Up to back of skull To behind eye(s) To shoulder or shoulders To upper back To arm To hand My neck pai n Do you have any of the following? * Associated headache Numbness or tingling to the arm or hand Facial numbness Slurred speech Weakness Dizziness What makes your neck feel worse? * Looking over shoulder Looking up Looking down Reading a book or on phone/computer When is your neck pain most problematic? First thing in the morning Towards the end of the day No specific time of the day Thank you!
