Please correct the errors described below.

Region of Complaint / Reason For Visit

0-10 Severity scale

- Mild pain / symptom range: 1-3
- Moderate pain / symptom range: 4-6
- Severe pain / symptom range: 7-10

Symptom severity are rarely at a static level. Often times they will vary based on activity, time of day, position, etc. In order to better understand your symptoms, please rate how you feel now, how you feel on average (since the condition started), how you feel at its best and how you feel at its worst.

In order to properly assess your condition, we must understand how much your neck and/or back problems has affected your ability to manage everyday activities. For each item, please select the number which most closely describes your condition right now

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