1-844-494-8376

F
R
A

SUFFERING
FROM
BACK PAIN?

Learn more about your pain and contribute to progress.

WHO ARE
WE?

We are the Quebec Pain Research Network and we work with our community to understand and alleviate your pain. Our goal is to help you improve your quality of life.

WHY TAKE
LESS THAN TWO MINUTES
TO FILL OUT
THIS FORM:

Learn more
about your
pain

Improve quality of life
of people suffering
from back pain

Acquire the possibility
to discuss with
a researcher

Contribute to
the advancement
of medical research

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Date of Birth (hidden)

PARTICIPATE IN
OUR ANONYMOUS
FORM

Answer these few questions without any other commitment.

Age
Please enter a number from 1 to 200.
Postal code
Sex
- Woman
- Man
- Unspecified

IN THE PAST 7 DAYS, HOW WOULD YOU RATE YOUR PAIN ON AVERAGE? FOR EACH OF THE FOLLOWING SECTIONS IN YOUR BACK?

Cervical
Since when has it been painful?*
- No pain
- 0-1 month
- 1-3 months
- 3+ months

Thoracic
Since when has it been painful?*
- No pain
- 0-1 month
- 1-3 months
- 3+ months

Lumbar
Since when has it been painful?*
- No pain
- 0-1 month
- 1-3 months
- 3+ months

Do you experience pain elsewhere?*

Yes
No

Foot
Ankle
Knee
Hip
Hand
Wrist
Elbow
Shoulder
Head

Comments

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For more information, feel free to contact us.

1-844-494-8376 | contact@backpainconsortium.ca

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