Pain Center of NJ Please Fill Out Our Pain Assessment Form Below https://paincenterofnj.com/wp-content/uploads/2019/02/AIJG6164.mp4 Pain Assessment Progress1 2 3 4 5 Tell Us About Your PainWhere does it hurt?*Choose all that apply: Lower Back Middle Back Neck Shoulders Arms Buttocks Knee Legs OtherWhere Is the Pain Strongest?* Lower Back Middle Back Neck ShouldersHow Long Have You Been Experiencing Pain:*1 month or Less1-6 months7-12 months1 year or more Tell Us About Your PainHow would you describe your pain? Sharp Burning Cramping Throbbing Quick Jolts of PainIs the injury work related?*YesNoIs the injury automobile accident related?*YesNo Tell Us About Your PainHave you undergone any of the following?Choose all that apply: CT Scan MRI X-Ray Nerve Conduction Study Other (Please Explain) NoneOther Explanation Tell Us About Your PainWhat’s your insurance plan?* Aetna United Health Care Oxford Horizon Cigna Bluecross Medicare Automobile Insurance Workers Compensation OtherIf other, please tell us about your insurance plan: Personal informationFirst Name**Last Name**Email** Primary Phone**Secondary PhoneBest Time to Call:**MorningMiddayAfternoonComments This iframe contains the logic required to handle Ajax powered Gravity Forms.