1.How would you rate your pain intensity?

0 - No Pain

1

2

3

4

5

6

7

8

9

10 - Extreme Pain

0 - No Pain

1

2

3

4

5

6

7

8

9

10 - Extreme Pain

2.I am seeing Dr. Smith today for:

Low Back Pain

Mid-Back Pain

Neck Pain

Headache

General Wellness

Maintenance Care

Non-Musculoskeletal Condition

3.Compared to your first visit to Dr. Smith for the condition you identified in question #2, your condition is?

Completely Gone

Much Better

Moderately Better

A Little Better

About the Same

A Little Worse

Much Worse