Evalution-form

Tell Us About Your Pain
1. What is your current level of pain? If your pain comes and goes then choose how severe the pain is on a typical pain episode.
0 ( no pain)1234567890(Extreme Pain)
2. What is your source of pain? (check all the apply)
Lower BackHerniated DiscMid BackBulging DiscLeg PainTingling in Toes or FeetNeckOther
3. What type of doctors have you seen for your pain? (check all the apply)
ChiropractorPain ManagementOrthopedic SurgeonNeurologistGeneral DoctorOtherNone
4. When did your pain begin?
Less than a month ago1-3 months ago3 to 12 months agoMore than a year ago
5. What medications or treatments are you receiving for your pain? (check all that apply)
Chiropractic TreatmentPhysical TherapyAccupunctureOpioid Pain MedicationMuscle RelaxantsNSAIDOther / UnsureNone

How Did it Happen?
6. How did the pain begin? (check all that apply)
Accident at HomeVehicle AccidentAccident at WorkJust BeganAfter SurgeryCame on GraduallyAfter an IllnessSports RelatedOther
7. Check any of the following tests you have had for this condition. (check all that apply)
MRICAT ScanX-RayEMGOther TestNone
8. Have you had any surgeries related to your existing pain?
YesNo
9. Have you had any of the following treatments /procedures? (check all that apply)
Joint InjectionTrigger Point InjectionsNerve BlockPercutaneous DiscectomyNone of the above

Tell Us About Yourself
10. Do you have any type of health or medical insurance?
YesNo
11. How serious do you view your condition?

12. Do you have any additional information about your condition you want us to know or any questions about treatment options we can help answer?

13. What Is Your First Name?

14. What is your Last Name?

15. What is your best email address? (used to send treatment qualification information)

16. What Is Your Best Contact Phone Number - Please Input Your Area Code Followed By Your Phone Number With NO SPACES, No Dashes, Or Parentheses

17. What Is Your Zip Code?

18. What is the best time to contact you?
Closer to 9amCloser to NoonCloser to 3pmCloser to 6pm

Monday	—–	9:30am to 1:30pm 3:00pm to 7:00pm
Tuesday	—–	2:30am to 7:30pm
Wednesday	—–	9:30am to 1:30pm 3:00pm to 7:00pm
Thursday	—–	1:30am to 7:30pm
Friday	—–	9:30am to 1:30pm 3:00pm to 7:00pm
Saturday	—–	Closed
Sunday	—–	Closed

Evaluation Form

Call us Now:
(610) 853-9000

Address:
510 Darby Rd, Ste.3A
Havertown, PA 19083, US

Rehab 2 Wellness

Office Hours

Office Hours

(610) 853-9000

(610) 853-9000

Evalution-form

Evaluation Form

Call us Now: (610) 853-9000

Address: 510 Darby Rd, Ste.3A Havertown, PA 19083, US

Rehab 2 Wellness

Office Hours

Office Hours

(610) 853-9000

(610) 853-9000

Call us Now:
(610) 853-9000

Address:
510 Darby Rd, Ste.3A
Havertown, PA 19083, US