Neck Pain Self-Test

Are You Tired of Neck Pain?

Are You Looking For Help?

This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage everyday life. Please answer every section and mark only ONE box that applies to you. We realize that you may consider that two of the same statements in any one section relate to you, but please just mark the box that most closely describes your problem.

Pain Intensity
Personal Care (Washing, Dressing, etc.)
Lifting
Reading
Headaches
Concentration
Work
Driving
Sleeping
Recreation

Your personal information will never be shared or sold. It will only be used by the Busch Chiropractic Pain Center to contact you regarding treatment.