New Patients

Complete Your Forms Before Your Visit

Save time at your appointment by completing the forms below before arriving.

Pain Diagram Neck Form Back Form

Step 1

Pain Diagram

Tell us where you are feeling pain, numbness, tingling, burning, or stiffness.

Patient Pain Diagram - Digital

First Name *

Last Name *

Date *

Phone

Pain Type / Symptoms *

Pain (P)

Tingling (T)

Numbness (N)

Burning (B)

Stiffness (S)

Other

Select all that apply.

Affected Body Area(s) *

Head

Neck

Left shoulder

Right shoulder

Upper back

Mid back

Low back

Left arm

Right arm

Left hand

Right hand

Left hip

Right hip

Left leg

Right leg

Left foot

Right foot

Select all that apply.

Pain Level 0-10 *

0 = no pain, 10 = worst pain.

Describe Your Pain

Where is it? When did it start? What makes it better or worse?

Patient Signature *

Clear

If you are human, leave this field blank.

Step 2

Neck Pain Questionnaire

Help us understand how neck pain affects your daily activities.

Neck Pain Disability Questionnaire - Digital

First Name *

Last Name *

Date *

Section 1 - Pain Intensity *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose the statement that best describes your neck pain today.

Section 2 - Personal Care *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how neck pain affects washing, dressing, and personal care.

Section 3 - Lifting *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how neck pain affects lifting.

Section 4 - Reading *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how neck pain affects reading.

Section 5 - Headaches *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose the statement that best describes headaches.

Section 6 - Concentration *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how pain affects concentration.

Section 7 - Work *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how pain affects work.

Section 8 - Driving *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how pain affects driving.

Section 9 - Sleeping *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how pain affects sleep.

Section 10 - Recreation *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how pain affects recreation.

Patient Signature *

Clear

If you are human, leave this field blank.

Step 3

Low Back Pain Questionnaire

Help us understand how low back pain affects movement, sleep, travel, and daily life.

Low Back Disability Questionnaire - Digital

First Name *

Last Name *

Date *

Section 1 - Pain Intensity *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose the statement that best describes your low back or leg pain today.

Section 2 - Personal Care *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how pain affects washing, dressing, and personal care.

Section 3 - Lifting *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how pain affects lifting.

Section 4 - Walking *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how pain affects walking.

Section 5 - Sitting *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how pain affects sitting.

Section 6 - Standing *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how pain affects standing.

Section 7 - Sleeping *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how pain affects sleeping.

Section 8 - Sex Life (if applicable)

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Optional section. Choose only if applicable.

Section 9 - Social Life *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how pain affects your social life.

Section 10 - Traveling *

0 - No pain / no difficulty

1 - Mild pain / slight difficulty

2 - Moderate pain / some difficulty

3 - Fairly severe pain / limited activity

4 - Very severe pain / major limitation

5 - Worst pain / unable to perform activity

Choose how pain affects travel.

Patient Signature *

Clear

If you are human, leave this field blank.

Need help completing your forms?

Call Morgante Family Chiropractic LLP at 716-833-2960.