Horizons Clinical Research Center, LLC
Questionnaire

    Questionnaire for those interested in participating in a research study for the
    treatment of Acute Low Back Pain.
How did you hear about us?
Are you 18 to 65 years of age?
 Yes
 No
If female are you pregnant or breastfeeding?
 Yes
 No
Do you have pain that radiates into your leg?
 Yes
 No
Do you have chronic low back pain?
Yes
 No
Do you have a rheumatologic disease such as rheumatoid arthritis,
ankylosing, spondylitis, etc.?
 Yes
 No
What is your height?
What is your approximate weight?
Your name:
Your e-mail address:
Your phone number:
Comments:
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