1. Location of pain:

 
 
 
 

2.Pain type:

 
 
 
 

3. Pain intensity (0-10):

 
 
 

4. Duration:

 
 
 

5. Do you experience:

 
 
 
 

6. Triggers:

 
 
 
 
 

7. Previous back injuries/surgeries?

 
 

8. Underlying medical conditions (e.g., diabetes, arthritis)?

 
 

9. Current medications?

 
 

10. Difficulty with:

 
 
 

11. Impact on daily life (0-10):

 
 
 

Question 1 of 11

Disclaimer: Remember, this self-screening tool is not a substitute for professional medical advice. If you’re concerned about your back pain, consult with a healthcare professional for an accurate diagnosis and treatment plan.

Quick Links

Request Appointment

Are You Ready To Live Pain-Free?

Latest Blogs

Chesterton Physical Therapy in Chesterton IN 46304

SUBSCRIBE TO OUR HEALTH BLOG

Ebook

Chesterton physical therapy MAY 2023 NEWSLETTER

Grab it All!

CELEBRATING OUR 19th YEAR OF SERVICE!

Close Welcome Bar

πŸ“˜ Wait! Don’t Leave Without Your Free eBook

Neck & Shoulder Pain Relief – No Meds. No Surgery.

Get expert tips and simple exercises to feel better β€” naturally and safely.

πŸ”’ We respect your privacy. No spam, ever. 🀝

βœ… Backed by certified experts at Chesterton Physical Therapy

πŸ’‘ Trusted by 1,000+ patients in Chesterton, Portage & Michigan City