Assessments to check for pain and discomfort levels

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Dr. Leipold will perform an initial exam as well as periodic re-exams to check your progress according to your treatment plan. If it is time for a re-exam, let's see how you're doing and possibly move to the next phase of treatment. If this is for your initial exam, we will use this as a baseline for your initial phase of treatment. Please answer the questions below and then submit to send securely.

Assessments for Neck, Shoulders, and/or Upper Back

The questions below say neck. Please answer the questions as though it is discussing the pain in the part of your body that hurts. If you have any pain or discomfort at all and want to be treated, you must answer the questions below.

Please check all that apply My pain is in my:

I'm not feeling any pain in my neck, shoulders, or upper back and do not want/need them treated at this time.

Back of neck

Left side of neck

Right side of neck

Base of skull

Bottom of neck where it touches your shoulders

Right shoulder

Left shoulder

Upper back between your shoulder blades

Assessment for Hips/Lower Back/Sacral Pain

The questions below say back. Please answer the questions as though it is discussing the pain in the part of your body that hurts. If you have any pain or discomfort at all and want to be treated, you must answer the questions below.

Please check all that apply: My pain is in my:

I'm not feeling any pain in my low back/hips/or sacrum at all and do not want/need them treated at this time.

Lumbar Region/Lower Back

Hips

Sacrum/Tailbone