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Pain Survey

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Step 1 of 8

12%

How would you rate your pain?*

Mild Pain

Moderate Pain

Severe Pain

How does your pain present itself? Check all that apply.*

Burning while running, dull at rest

Sharp and intense while running and at rest

Pain that does not lessen after running

Discomfort that lessens within a few days of running

Tightness/soreness at beginning of run

Consistent or increasing pain while running

Discomfort isolated in muscles

Pain in muscles and joints

Pain during or shortly after running

Pain before, during, and after running

Pain and swelling after a workout

None of the above

How has your pain affected you? Check all that apply.*

I have had to change my gait while running to lessen the pain

I have trouble walking or going about my day after running

My running performance has been affected due to pain

I have trouble sleeping and often feel fatigued

None of the above

Where are you experiencing pain? Check all that apply.*

Knees

Shins

Ankles

Feet

Hips

Lower back

Neck and Shoulders

Head

Chest

Other

None of the above

Where are you experiencing pain in your knees? Check all that apply.*

Pain outside the knee

Pain under or around kneecap

Pain throughout knee, going to top of shins

Other

Where are you experiencing pain in your shins? Check all that apply.*

Pain in the front of shins

Pain in the inside/back of shins

Pain when touched

Other

Tell us more about your foot pain - Check all that apply.*

Numbness or tingling sensation

Sharp/sudden pain while running

Pain that worsens while running

Other

Describe the pain in your hips - Check all that apply.*

Pain or swelling in joints

Discomfort in muscles at front of hips

Pain on the outside of hips

Other

Describe the pain you feel in your chest - Check all that apply.*

Dull ache while breathing during run

Pain that spreads from chest to neck and shoulders

Pain accomanied by nausea or dizziness

Pain across diaphragm, or "side stitches"

Please tell us about any other pain you may be experiencing before, during, or after a run!

How has this pain impacted your social activities?

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Cell Phone*

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Get in Touch

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(609) 845-3585

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info@southjerseypt.com

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1299 Route 38, Suite 9, Hainesport, NJ 08036

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Hours

Monday 9:00 AM - 7:00 PM

Tuesday 9:00 AM - 6:00 PM

Wednesday 9:00 AM - 6:00 PM

Thursday 9:00 AM - 7:00 PM

Friday 9:00 AM - 6:00 PM

Saturday Closed

Sunday Closed

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