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NeckLow BackButtocksHipLegCalfFoot

Less than a monthMore than 6 wksMore than 6 monthsMore than 1 yr

DullSharpBurningTinglingShootingNumbnessThrobbing

Intermittent (0-25% of day)Occasional (26-50% of day)Frequent (51-75% of day)Constant (76-100% of day)

YESNO

YESNO

YESNO

Disc HerniationDisc BulgeSciaticaSpinal StenosisDisc DegenerationSpondylolisthesis

Pain SittingPain StandingTrouble WalkingInterrupted Sleep at nightDecreased ActivitiesDecreased Pace

AMPM





YESNO

MorningAfternoonEvening

TextCall