Horizons Clinical Research Center, LLC
Questionnaire
© Copyright 2007 Horizons Clinical Research Center, LLC / All Rights Reserved
    Questionnaire for those interested in participating in a research study for the
    treatment of Chronic Low Back Pain.
How did you hear about us?
Are you at least 18 years of age?
 Yes
 No
If female are you pregnant or breastfeeding?
 Yes
 No
Have you been taking pain relievers for low back pain for at least the past 3
months, and at least 4 times per week?
 Yes
 No
Have you had any major trauma to the back in the past 6 months?
 Yes
 No
Have you had back surgery within the past 6 months?
 Yes
 No
Have you had more than one back surgery?
 Yes
 No
If female do you have endometriosis?
 Yes
 No
Have you known history of rheumatoid arthritis, Spinal stenosis associated
with neurological impairment, fibromyalgia, or psoriasis?
 Yes
 No
Have you had gastric bypass surgery?
 Yes
 No
Have you had a herniated disc associated with neurological
impairment in the past 2 years?
 Yes
 No
Your name:
Your e-mail address:
Your phone number:
Comments:
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