Medical Self-Checks painHEALTH medical self-checks multi-step form to help identify musculoskeletal pain. Step 1 of 4 25% Please tick all that apply I am taking recreational drugs I take alcohol I am taking/have taken corticosteroids I have/have had angina or heart problems Since this problem started I have had a sudden onset of severe, steady and worsening middle abdominal and upper back pain I have had cancer at some time in the past Have you recently experienced any of the following? I have experienced significant physical or emotional trauma I have had unexpected weight loss I have had recent fever associated with the current episode of pain I have had bowel or bladder weakness or retention I have/have had constipation I have numbness or pins & needles in my hands or feet or in my groin region or difficulty with balance/walking I have had heat, swelling, pain and other symptoms or tenderness in my calf I have trouble putting my weight through my legs (e.g. walking) due to pain) I am diabetic I am on Warfarin or another 'blood thinner' Have you recently experienced any of the following? I have had dizziness, blurred vision, slurred speech, difficulty swallowing, falls or unsteadiness I have had seizures / fits / epilepsy I have had stomach ulcers I have/have had a history of kidney disease Please tick all that apply I think I may be depressed Have you experienced significant stress from any of these sources? I have experienced stress from work I have experienced stress from home I have experienced stress from my social circle I have experienced stress from my financial situation I have experienced stress from contact with health professionals I have experienced stress from concerns of future disability relating to my pain I have experienced stress from abuse of any kind as a child or teenager. This iframe contains the logic required to handle AJAX powered Gravity Forms.
