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