Health Assessment Questionnaire

Help us understand your health concerns - Answer in simple, everyday language

1

About You

This helps us understand what activities might be affecting your health
2

Important Warning Signs

Please check any of these that apply to you. These are important warning signs that need immediate attention:

3

Where Are You Having Problems?

Click on all the body parts where you're experiencing pain, discomfort, or problems:

Head
Neck
Shoulder
Upper Back / Chest
Upper Arm
Forearm
Wrist
Hand / Fingers
Stomach / Belly
Upper Back
Lower Back
Groin / Hip
Buttock
Front Thigh
Side Thigh
Inner Thigh
Back Thigh
Front Shin
Calf
Side Lower Leg
Ankle
Foot / Toes
4

Tell Us About Your Pain

No pain Worst pain ever
0
Move the slider: 0 = no pain, 5 = moderate pain, 10 = unbearable pain
Check all that describe your pain:
6

Your Medical Background

Include any conditions you're being treated for or have had in the past
Include prescription drugs, over-the-counter medications, vitamins, and supplements
Anything else about your symptoms, concerns, or goals
×

Your Assessment Results

IMPORTANT: Urgent Medical Attention Needed

Based on your responses, you should seek immediate medical attention. Please contact your doctor or go to the emergency room.