Back Pain Survey

Cure-Back-Pain.Org proudly presents the official online version of the back pain survey distributed worldwide by Sensei Adam Rostocki. This survey has already been taken by over forty thousand patients who were kind enough to provide their personal experiences with back pain. The results of this survey are an important part of the research which fuels this website. One moment of your time will help other patients to cure their own pain. Do something good for fellow patients around the globe. Share your experiences and maybe help to change a life�

No personal information acquired as part of this survey will be shared with any other entity. You will not be placed on any mailing list from your participation in this survey. The only email you will receive is a confirmation of your participation�

Please be honest and accurate with your survey. Your results ARE IMPORTANT. This is YOUR CHANCE to make a real difference in the way back pain is diagnosed and subsequently treated. Thank you for your time and contribution.

BACK PAIN SURVEY

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

E-mail Address*
E-mail Address*

Country*
Country*

Gender

	Female
	Male

Age

	Under 18
	18 to 25
	26 to 35
	36 to 45
	46 to 55
	56 to 65
	66 to 75
	over 76

Diagnosis (check all that apply)

	Degenerative Disc Disease
	Facet Joint Syndrome
	Fibromyalgia
	Herniated Disc
	Kyphosis
	Lordosis
	Muscle Problems
	Pinched Nerve/Foraminal Stenosis
	Piriformis Syndrome
	Sacroiliac Joint Dysfunction
	Sciatica
	Scoliosis
	Spinal Arthritis
	Spinal Stenosis
	Spondylolisthesis
	TMS/Psychosomatic

Optional Comments on Diagnosis:

Location of Symptoms (check all that apply)

	Neck
	Upper Back
	Middle Back
	Lower Back
	Buttocks
	Legs
	Feet
	Shoulder
	Arms
	Hands
	Hips/Pelvis

Optional Comments on Symptom Location

Length of Symptoms (total)

	Less than 3 months
	Less than 6 months
	Less than 1 year
	1 to 3 years
	3 to 10 years
	10 to 20 years
	20 years or more

Optional Comments on Duration of Symptoms:

Frequency of Symptoms

	Once
	A Few Isolated Occurrences
	Occasional
	Somewhat Frequent
	Frequent
	Regular
	Almost Constant
	Always

Optional Comments on Symptom Frequency

Severity of Symptoms

	Annoying
	Mild
	Moderate
	Severe
	Extreme
	Beyond Measure

Optional Comments on Symptom Severity:

Treatments Received (check all that apply)

	Acupuncture
	Alexander Technique
	Alternative Medicine (specify below)
	Chiropractic
	Complementary Medicine (specify below)
	Dietary Therapy
	Drugs/Medicines
	Electrotherapy/TENS
	Epidural Injections
	Knowledge Therapy
	Physical Therapy
	Spinal Decompression
	Surgery (outpatient minimally invasive)
	Surgery (full procedure)
	Other (specify below)

Optional Comments on Treatment History:

Did Any of These Treatments Cure You Completely?

	No
	Yes

If so, Which one worked for you?

Treatment Results ( How you feel now, after treatment)

	I am completely well
	I still have a little pain
	I have occasional moderate pain
	I have constant moderate pain
	I have occasional severe pain
	I have constant severe pain
	I have occasional extreme pain
	I have chronic extreme pain

Optional Comments on Treatment Results:

What Effect has Back Pain had on Your Life?

	None
	Minor Effect
	Moderate Effect
	Significant Effect
	Severe Effect
	It Controls My Life

Optional Comments on Pain Effects

Has this website, Cure-Back-Pain.Org been helpful to you?

	No
	A Little
	Somewhat Helpful
	Very Helpful
	Super Helpful

Optional Comments on the site:

Once again, thank you for taking the Back Pain Survey!

You might also be interested in sharing your back pain story with us.

Thank you also to the many volunteers who continue to distribute the paper version of this survey. Your diligent work is much appreciated!

Back Pain Survey to Home Page 7/11/07 Revised 5/7/08