Put a check in the box for any symptoms that you have

1. Can you touch the place where your pain is coming from with a finger?

2. If you press on this area does it hurt worse with pressure?

3. Does your pain increase with prolonged standing or sitting?

4. Does your pain improve with activity or movement?

5. Does your pain get better at times, then worse again at other times for no obvious reason?

6. Was your pain originally stimulated by a traumatic injury?

7. Have you been diagnosed as having a ligament sprain or tear?

8. Do you often sit with your legs crossed to minimize pain in your low back?

9. Do joint problems and pain run in your family?

10. 10. Does your pain improve with chiropractic manipulation, only to worsen after a few days or weeks?

11. Do you have indigestion, bloating, diarrhea or constipation?

12. Have you been diagnosed with “tendonitis”?

13. Have you ever suffered from a “Whiplash” Injury?

<3 Prolotherapy is not likely to be useful
3-5Prolotherapy may be beneficial and you should schedule an evaluation with Dr. Camp
>5 Prolotherapy will very likely be beneficial and you should schedule an evaluaton with Dr. Camp
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