Tell Us About Your Pain Please Fill Out Our Pain Assessment Form BelowStep 1 of 5 - Pain Assessment Progress20%Tell Us About Your PainWhere does it hurt?*Choose all that apply: Lower Back Middle Back Neck Shoulders Arms Buttocks Legs OtherHow Long Have You Been Experiencing Pain:*1 month or Less1-6 months7-12 months1 year or more Describe Your Pain for UsHow would you describe your pain? Sharp Burning Cramping Throbbing Quick JoltsAre you always in pain?*Yes, I am in constant pain that worsens depending on what activity I am doing.No, it comes and goes depending on what activity I am doing.Do you have any of the following Symptoms? Pins and Needles Feeling Numbness Tingling Sensations Progressing Weakness Loss of Coordination None Tell Us About Your Past TreatmentHave you undergone any of the following? CT Scan MRI X-Ray Nerve Conduction Study Other None What’s your insurance plan?*AetnaAetna Aexcel – designated SpecialistsAetna Whole Health – Seton Health AllianceAetna Medicare Open PlanAffordable Health SystemsAmeriHealthBlue Cross/Blue Shield PARPLANBC/BS Blue ChoiceBC/BS Blue Choice BASICBC/BS Health SelectBC/BS Fed SelectBlue SolutionsCAPP CareCIGNA *Designated physician ends 12/31/2014DocFIRST (Nextel Employees)OneSource Health NetworkEmployers Medical Provider Network (EMPN)EPICETHIX SouthwestCoventry Health CareHMO BlueUnited HealthCare *Premium DesignationGreat West HealthcareHumanaHumana CHOICEHumana Fee for Service MedicareInjury Management Organization Med-SelectMultiPlanNational Preferred Provider NetworkPhysicians Health Choice (WellMed)Prime Health Services Texas Health NetworkSeton Health AllianceSeton Physician Hospital Network (SPHN)– Admar/Med Network– Accountable Health Plan– Affiliated Healthcare– Anthem Health Systems– BeechStreet / PPO Next– Benefit Planners– Central Texas Provider Network– ChoiceOne– Coventry– FirstCare– FirstHealth High Performance PPO– Galaxy Healthcare– Health Payors Organization– HealthSmart ACCEL– HealthSmart Preferred– Healthy Equations– Integrated Medical Systems– Medical Control (Net One)– Mega Life– MultiPlan– National Healthcare Alliance– Seton Health Plan– SmartHealth (effective January 1, 2013)– Texas Bankers Association– Texas Municipal League– Texas True Choice– Texas True Choice Leander ISD– UniCare Classic– UniCare Performance– USA Managed Care NetworkCapital Area Providers (CAP)– Accountable Health Plan– Affiliated Healthcare– BeechStreet– CIGNA– First Health– Galaxy– Great West Healthcare– HealthSmart ACCEL– Independent Medical Systems– Multi Plan– Texas Municipal League– Texas True ChoiceSouthwest Medical Provider NetworkSt. Luke’s SocietyTexas Star Network (Texas Mutual)TriCare (Humana Military)TRS ActiveCare (Administered by BCBS)Medicare (including most replacement plans)WellMed (Medicare)Work Comp Non SubscribersWorkersOtherIf other, please tell us about your insurance plan: Last Name*First Name*Email* Phone*How would you like us to contact you?*By EmailBy PhoneComments This iframe contains the logic required to handle Ajax powered Gravity Forms.