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Order Number
20% Completed
10% Completed
1. Have you had back pain?
Question1
2 weeks to 1 month
1 month to 6 months
6 months to 1 year
Longer than 1 year
I don’t feel any back pain
40% Completed
10% Completed
2. Do you experience:
Question2
Headaches
Neck ache
Stiffness
Pain that worsens with inactivity
None of the above
60% Completed
10% Completed
3. Some details about you:
Age
*
Height (cms)
80% Completed
10% Completed
4. Do you experience:
Question3
Muscle fatigue
Stiffness in the joints
Difficulty bending down
Tension while walking or shifting positions
None of the above
90% Completed
10% Completed
5. Almost done…
Name
*
100% Completed
10% Completed
6. Do you experience:
Question4
Sharp, shooting pains
Pain in one particular part of the back or body
Pain during or after activity
Stiffness first thing in the morning
None of the above
100% Completed
10% Completed
total