Perfect Balance Clinic

Region of pain *

A great place to start with your pain is to understand where the pain actually is. This is useful because it will give us an idea of what could be wrong with you based on where the pain is. Some areas of pain are less serious than others.

Where is your pain?

Using the image on the right please select the area on your body that is painful.

Screening Questions *

Please tell us if any of the following apply to the type of pain you are suffering from?

(Please slide the green dot along the bar)

How long have you had the pain *

Please tell us approximately how long you have had your pain

(Please slide the green dot along the bar)

Do you play regular sport? *

So that we can get an idea of how active you are physically, can you tell us if you play regular sport, visit the gym or are generally physically active

How would you describe your pain? *

Please select the closest statement that describes the type of pain you are experiencing

Does the pain spread out? *

Please let us know if you are experiencing pain which spreads out

Has the pain been getting worse? *

Please tell us if the pain has been getting worse since it first started

Does the pain change? *

Please let us know if the pain that you currently have changes at all

How severe is the pain *

So we can understand the level of pain you are experiencing, please can you rate your pain out of 100

Have you seen anyone for this problem before? *

Please let us know if you have seen anyone for this pain before. This might include your GP, Physio, Osteopath, Chiropractor or another Specialist.

Pain Questionnaire

Your Results so far

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