Cure-Back-Pain.Org proudly presents the official online version of the back pain survey distributed worldwide by Sensei Adam Rostocki. This survey has already been taken by over 1 million, 1 hundred thousand (1,100,000) patients who were kind enough to provide their personal experiences with back pain over the past 2 decades.
The results of this survey are an important part of the research which fuels this website. Although we are no longer processing survey results, we continue to make this survey available to care providers who want to chart their own patient interactions with back pain sufferers.
Below, please find a shortened version of our original Back Pain Survey:
Gender:
Female
Male
Age:
Under 18
18 to 25
26 to 35
36 to 45
46 to 55
56 to 65
66 to 75
over 76
Diagnosis (check all that apply):
Degenerative Disc Disease
Facet Joint Syndrome
Fibromyalgia
Herniated Disc
Kyphosis
Lordosis
Muscle Problems
Pinched Nerve/Foraminal Stenosis
Piriformis Syndrome
Sacroiliac Joint Dysfunction
Sciatica
Scoliosis
Spinal Arthritis
Spinal Stenosis
Spondylolisthesis
TMS/Psychosomatic
Optional Comments on Diagnosis:
Location of Symptoms (check all that apply):
Neck
Upper Back
Middle Back
Lower Back
Buttocks
Legs
Feet
Shoulder
Arms
Hands
Hips/Pelvis
Optional Comments on Symptom Location:
Length of Symptoms (total):
Less than 3 months
Less than 6 months
Less than 1 year
1 to 3 years
3 to 10 years
10 to 20 years
20 years or more
Optional Comments on Duration of Symptoms:
Frequency of Symptoms:
Once
A Few Isolated Occurrences
Occasional
Somewhat Frequent
Frequent
Regular
Almost Constant
Always
Optional Comments on Symptom Frequency:
Severity of Symptoms:
Annoying
Mild
Moderate
Severe
Extreme
Beyond Measure
Optional Comments on Symptom Severity:
Treatments Received (check all that apply):
Acupuncture
Alexander Technique
Alternative Medicine (specify below)
Chiropractic
Complementary Medicine (specify below)
Dietary Therapy
Drugs/Medicines
Electrotherapy/TENS
Epidural Injections
Knowledge Therapy
Physical Therapy
Spinal Decompression
Surgery (outpatient minimally invasive)
Surgery (full procedure)
Other (specify below)
Optional Comments on Treatment History:
Did Any of These Treatments Cure You Completely?
No
Yes
If so, Which one worked for you?
Treatment Results ( How you feel now, after treatment):
I am completely well
I still have a little pain
I have occasional moderate pain
I have constant moderate pain
I have occasional severe pain
I have constant severe pain
I have occasional extreme pain
I have chronic extreme pain
Optional Comments on Treatment Results:
What Effect has Back Pain had on Your Life?
None
Minor Effect
Moderate Effect
Significant Effect
Severe Effect
It Controls My Life
Optional Comments on Pain Effects:
Has Cure-Back-Pain.Org been helpful to you?
No
A Little
Somewhat Helpful
Very Helpful
Super Helpful
Optional Comments on the site:
