5-Minute Pain Assessment
Are you suffering from any of the following symptoms?
Back pain
Neck pain
Headaches
Arm or shoulder pain
Leg or foot pain
Hand or wrist pain
Hip pain
Joint pain
Jaw pain
Numbness
Tingling
Stiffness
Muscle twitching
Burning sensation
Cramping
Difficulty sleeping
Cold hand, cold feet
Poor coordination
None
How is your posture from the side?
Normal Posture
Hollow Back
Rounded Shoulders or Head Forward
Tucked Pelvis
How is your posture from the front? (Choose one answer per row)
HEAD: Ears level.
HEAD: Slightly tilted.
HEAD: Significantly tilted.
SHOULDERS: Level
SHOULDERS: One slightly higher than the other.
SHOULDERS: One significantly higher than the other.
HIPS: Level.
HIPS: One slightly higher than the other.
HIPS: One significantly higher than the other.
Are the length of your legs uneven?
(Instructions: Lay flat on your back and bend your legs at the knee. Ask a friend or use a handheld mirror to see if one of your heels is higher. Also: Do you pant leg lengths look uneven? Do your shoes have uneven signs of wear?)
Yes
No
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