• Neck and Upper Back
  • Lower and Middle Back
  • Buttocks or Legs
General Info    
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Height
Weight
Age
Did the pain begin soon after an injury or lifting?
No
Yes
In which area of your body are you experiencing pain?
Buttocks or Legs
Middle or Lower Back
Neck or Upper Back
Sex
Female
Male
 
Height units
Inches
Metres
Weight units
Kilograms
Pounds
When did the symptoms begin?
Between 1 month and 1 year
Between 1 week and 1 month
Less than a week
Over a year
Do you have a history of back pain?
No
Yes
How would you describe the type of pain you experience?
Aching
Numb
Sharp
 
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