Email *

Age *

For Back pain, what is the exact location? *
UpperMidLower

What caused your first pain episode?*
BendingFall/AccidentPicked up something heavyAt the gym/Playing sportNone of the above

For how long have you had this pain?*
Less than 7 days7 days - 1 month1 - 3 monthsMore than 3 months

Which of the below make your pain better?*
SittingBendingStandingWalkingLying downCarrying weightNone of the above

Since it has started, has your condition changed?*
It is improvingIt is worseningIt is almost the same

Have you been diagnosed with any of the following?*
Severe osteoporosisTuberculosisCancerSpine fractureDiabetesStrokeParkinson's diseaseBlood pressureThyroidTuberculosis or spine functionRheumatoid arthritisNone of the above

Are you currently on any medications?*
Pain killersCardiacCalcium supplementLung relatedVitamin supplementMuscle relaxantsAntidepressantsSteroidsNone of the above