Pain Assessment Step 1 of 3 - Area of pain 33% Tell us where the pain is*Pick one area only, then click the Next button.Head & neckShoulderElbowHipHand & wristKneeFoot & ankleLower back 1. What kind of pain is it?*A dull acheSharp and stabbingA dull ache but with sharp pain on movement2. Are your symptoms…*Constant pain is unaffected by rest, symptoms are present morning, noon and night. Intermittent pain may become aggravated during or after exercise and relieved with rest.Constant ('there all the time')Intermittent ('comes and goes')3. Are your symptoms…*Localised? ('in one place')Radiating? ('in several places')4. Are your symptoms due to a single event trauma, accident or injury?*Single event trauma for example could be sudden impact through sport, falling off a ladder or while lifting a heavy object. Progressive pain tends to come on during or after exercise and physical exertion.Single event trauma (including injury or accident)Progressively (recurring pain over a period of time)5. Is there or has there been swelling or bruising in to the pain area?*YesNo6. Is the pain area red or does it feel hot?*YesNo7. Are your symptoms…*Worse in the morning?Worse later in the day?The same regardless of the time of day?8. Are your symptoms…*Aggravated by movement or exercise?Relieved by movement or exercise?Relieved during exercise but then worse afterwards?9. When did your symptoms first begin?*Less than six weeks ago?More than six weeks ago?10. Are you experiencing numbness, pins and needles or shooting pain into the extremities (e.g. hands, legs or feet)?*YesNoSometimes11. Are your symptoms worse when you cough or sneeze?*YesNo12. Is your normal range of movement reduced or affected?*YesNo13. Does the pain area ever lock or spasm?*YesNo 14. How old are you?*Under 18 years18 - 55 yearsOver 55 years15. Are you..*MaleFemale16. How often do you exercise or do sports?*More than 5 times per weekOnce or twice per weekOccasionallyNever17. How often do you smoke?*More than 10 cigarettes a dayLess than 10 cigarettes a dayOccasionallyNever18. Is there a history of degenerative bone disease in your family (e.g. osteoarthritis, osteoporosis or rheumatoid arthritis)?*YesNo19. How do you spend your time at work?*Mostly sittingBoth sitting and standingMostly standing20. Does your job involve heavy lifting or carrying?*YesNo21. How many hours a night do you sleep on average?*8 hours or more5 - 8 hoursLess than 5 hours22. How would you describe your normal sleep quality?*GoodAveragePoorFoot-ankle-1foot-ankle-2elbow-1elbow-2hand-wrist-1hand-wrist-2knee-1knee-2knee-3knee-4head-neck-1head-neck-2head-neck-16head-neck-9head-neck-17head-neck-10head-neck-11head-neck-18head-neck-15head-neck-19head-neck-20head-neck-21head-neck-3head-neck-7head-neck-8head-neck-12head-neck-13head-neck-14head-neck-4head-neck-6head-neck-5low-back-1low-back-2low-back-3low-back-5low-back-15low-back-18low-back-19low-back-20low-back-21low-back-7low-back-16low-back-17low-back-8low-back-9low-back-22low-back-23low-back-24low-back-25hip-1hip-2hip-3hip-4hip-5hip-6hip-7hip-8hip-9hip-10shoulder-1shoulder-2shoulder-3shoulder-4shoulder-5shoulder-6shoulder-7shoulder-8shoulder-9shoulder-10NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.