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Modern Rejuvenation Center
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Home
About Us
Services
Aesthetics
Chemical Peel
Microblading
Microneedling
Body Sculpting
Hormone Therapy
BHRT
Women Hormone Therapy
Mens Hormone Therapy
Functional Medicine
Injectables
Botox
Fillers
Xeomin
Injectable Parties
What is PDO Thread Lift?
Memberships
Shop
Contact Us
Blog
Pain Assessment Tool
Step
1
of
5
20%
Choose All That Apply
Lower Back
Middle Back
Neck
Shoulders
Arms
Buttocks
Legs
Other
Where is the Pain Strongest?
Lower Back
Middle Back
Neck
Shoulders
How Long Have You Been Experiencing Pain?
1 Month or Less
1-6 Months
7-12 Months
1 Year or More
How Would you describe your pain?
Sharp
Burning
Cramping
Throbbing
Quick Jolts of Pain
Dull/Achy
Stiffness
Are you always in pain?
Yes, I am in constant pain that worsens depending on what activity I am doing.
No, it comes and goes depending on what activity I am doing.
Do you have any of the following Symptoms?
Pins and Needles Feeling
Numbness
Tingling Sensations
Progressing Weakness
Loss of Coordination
Have you undergone any of the following?
CT Scan
MRI
Nerve Conduction Study
Other (Please Explain)
None
Other Explanation
What’s your insurance plan?
If other, please tell us about your insurance plan:
Name
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First
Last
Email
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Phone
(Required)
Best Time To Call
Morning
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