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Neck/Upper Back (Assessment)

Complete the following form prior to your visit. 

Neck / Upper Back

This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability. 

Please select the answers below that best apply.

1. Pain intensity:
2. Personal Care (washing, dressing, etc.):
3. Lifting:
4. Headache:
5. Recreation:
6. Reading:
7. Work:
8. Sleeping:
9. Concentration:
10. Driving:

Thanks for submitting! Please let us know what questions you have, otherwise we'll look forward to seeing you soon!

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