Village Family Clinic:

What is your current pain level? 10 being most sever *

-- Please select -- 1 2 3 4 5 6 7 8 9 10

Where is your biggest source of your pain *

-- Please select -- Neck Back Knee Shoulder Arms Legs Head Other Other

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Do you have trouble with any of the following activities *

-- Please select -- Communicating Breathing Eating Drinking Washing Mobilization Working Playing Sports Sleeping Sexuality Parenting Househould Chores Emotional Health

How commited are you to fixing your problem? *

-- Please select -- Very Committed Somewhat Committed Neutral Not Committed Yet