top of page
Signing a Contract

Neck / Upper Back

Please complete the following:

Neck / Upper Back (Assessment)

This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability. 

Please select the answers below that best apply.

1. Pain Intensity
2. Personal Care (washing, dressing, etc.)
3. Lifting
4. Headache
5. Recreation
6. Reading
7. Work
8. Sleeping
9. Concentration
10. Driving

Thanks for submitting! Please let us know what questions you have, otherwise we'll look forward to seeing you soon!

bottom of page