Back and Neck Pain Study
 

Questionnaire

1. How did you hear about this study?
     Newspaper advertisement  Radio news story 
     Newspaper article  Television news story 
     Brochure received in mail Doctor referral
     Website/internet  Friend referral 
     Other 

2.  What is your zip code?
    
3.  What is your date of birth?
       MM/DD/YYYY
 

4.  Are you male or female?
     Male     Female 
    

5.  Are you currently pregnant?
     Yes      No
 

6.  Do you have pain in your neck or back?
     Yes      No
 

7.  Do you frequently take some sort of medication for your back pain?
     Yes      No
 

8.  On average, how often do you take medication for your low back pain?
     Less than once a week

     Once a week

     Twice a week

     Three times a week

     Four or more times a week
 

9.  Is your back pain caused by a major injury, such as a fractured spine or vertebrae, which occurred within the last 6 months?
     Yes      No
 

10. Have you had surgery on your back during the last 6 months?
     Yes      No
 

11. Are you currently receiving any treatments for your back?
     Yes      No
   

12. Has your doctor told you that you have rheumatoid arthritis?
     Yes      No
 

13. Have you been treated for a life-threatening cancer in the past 2 years?
     Yes      No
 

     If yes, were you treated for skin cancer or another form of cancer?
     Skin     Other
 

14. Have you ever received a Botox, Accupuncture, cortisone or other injections for your back pain?
     Yes      No
 

If yes, when did you receive the injection?

           MM/DD/YYYY
 

15. Do you currently have a pending worker's compensation claim, litigation or any other financial settlement claim related to your back pain?
     Yes      No

 

16. Are you currently taking a prescription medication for your back pain?
     Yes      No

 

If yes, what pain medication are you currently taking for your lower back pain?

        

 

17. Please describe what you believe is causing your back pain.
    
 

18. What is your first and last name?
    
 

19. What is your address?
     Street
     City
     State
     Zip Code
 

20. What is your daytime phone number?
        xxx-xxx-xxxx
 

21. What is your evening phone number?
       xxx-xxx-xxxx    
 

22. When is the best time to contact you?
    Daytime     Evening
 

23. What is the best way to contact you?
    Phone        E-mail
 

24. What is your e-mail address?
    
 

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