Pain Evaluator - Central Texas Spine Institute

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Where does it hurt?

Tell us more about your pain so we can help you
get the proper treatment.

Step 1 of 5 - Pain Assessment Progress

20%

Tell Us About Your Pain
Where does it hurt?*
Choose all that apply:
- Lower Back
- Middle Back
- Neck
- Shoulders
- Arms
- Buttocks
- Legs
- Other
How Long Have You Been Experiencing Pain:*
- 1 month or Less
- 1-6 months
- 7-12 months
- 1 year or more

Describe Your Pain for Us
How would you describe your pain?
- Sharp
- Burning
- Cramping
- Throbbing
- Quick Jolts
Are 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 Treatment
Have you undergone any of the following?
- CT Scan
- MRI
- X-Ray
- Nerve Conduction Study
- Other
- None

What’s your insurance plan?*
If other, please tell us about your insurance plan:

Last Name*
First Name*
Email*
Phone*
How would you like us to contact you?*
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Central Texas Spine Institute
3003 Bee Caves Rd., Suite 202 Austin, TX 78746
Hours 8 AM - 4:30 PM Monday - Friday
© 1988-2016 Central Texas Spine Institute - PLLC

Services
▼
Dr. Randall Dryer
▼
Healthcare Professionals
Patient Resources
▼
New Patients
▼
- New Patient Forms
- FAQ
About
▼
- Our Office
- Blog
Make A Payment
Contact
▼