Please enter your pain scores below. If you have any questions or if you have any problems entering your pain scores, please call Ortho Kinematics at 512-806-0380

CRF4 Lumbar Online Form

CRF4: Lumbar Patient Pain Scores

A. INSTRUCTIONS-

This questionnaire has been designed to give the doctor information about how your pain has affects your ability to manage in everyday life. Please answer every section and select one statement in each section. We realize you may consider that two of the statements in any one section relate to you, but only SELECT THE STATEMENT WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM.

B. QUESTIONAIRE:

C. Back Pain Visual Analog Scale

Indicate the severity of BACK your pain by clicking on the red line to describe your pain TODAY ranging from 'No Pain' to 'Worst Possible Pain'

D. Leg Pain Visual Analog Scale

Indicate the severity of your LEG pain by clicking on the red line to describe your pain TODAY ranging from 'No Pain' to 'Worst Possible Pain'

E. ADDITIONAL TREATMENTS