"*" indicates required fields Step 1 of 5 20% When back or neck pain makes daily tasks harder or keeps you from the activities you enjoy, it’s time to get expert help—without needing a referral. Use the following spine pain assessment to get started on a direct path to healing:Where is Your Pain?* Back Neck Other body part, but I know it's coming from a back or neck problem What could be causing your neck or back pain?* New injury Previous injury Possibly weight Long-term wear and tear I’m not sure Other During the Past Four Weeks:How would you describe your neck or back pain?* No pain Very mild Mild Moderate Severe Have you had trouble moving without assistance because of your neck or back pain?* No trouble at all Very little trouble Some trouble Extreme difficulty Walking or moving is impossible This could include bending down or standing up, moving your head side to side, twisting, etc.Have you struggled to get in and out of vehicles because of your neck or back pain?* No trouble at all Very little trouble Some trouble Extreme difficulty Impossible to do How often do you experience pain in your neck or back while resting or relaxing?* Never Not often (once a week) Sometimes (more than once a week) Often (almost daily) Constant (daily During the Past Four Weeks:How long can you walk independently without feeling pain or discomfort? (without the use of assistance from either a brace or another device)* More than 30 minutes (no pain) 16 to 30 minutes 5 to 15 minutes Around the house only Not at all (severe pain any time I’m walking) Can you move your head from side to side without pain or discomfort?* Yes, easily With a little difficulty With moderate difficulty With extreme difficulty No, the pain is too strong Have you had trouble falling or staying asleep because of neck or back pain or discomfort?* Not at all One or two nights a week Some nights Most nights Every night During the Past Four Weeks:Have you tried over the counter or prescription medications to help relieve the pain or discomfort?* Yes No Have you had bowel or bladder dysfunction that may be related to your back or neck pain?* Yes No Submit your answers, and we'll email you the results. We'll also follow up with next steps and contact information to help you get closer to returning to the activities you love.Disclaimer OrthoNebraska pain assessments are not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. For a full diagnosis, schedule an appointment with one of our specialists, visit an OrthoNebraska Orthopedic Urgent Care or our emergency room. You understand that by completing this form, you are consenting to receive phone and email communications from OrthoNebraska, but you can opt-out at any time.Have you had surgery on your neck or back (anywhere associated with your spine) in the past?* Yes No Have you ever been a patient at OrthoNebraska?* Yes No What is Your Gender?* Male Female Non-Binary or Other Name* First Name Last Name Phone*Email*