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"herniated disc pain for 5 months": Back Pain Community

"herniated disc pain for 5 months": Back Pain Community 2026

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The document is a Back Pain Questionnaire designed for individuals applying for life insurance with The Wawanesa Life Insurance Company. It includes questions about past and current back or neck pain, treatment history, causes of pain, and any related medical investigations or surgeries. The questionnaire requires the applicant to provide detailed information regarding their condition and concludes with a declaration statement confirming the accuracy of the provided information.

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Click ‘Get Form’ to open the questionnaire in the editor.
Begin by filling in your name at the top of the form. This personalizes your submission and ensures accurate processing.
Answer the first question regarding past pain or discomfort in your back or neck. Indicate 'Yes' or 'No' and provide details about the dates and duration of episodes.
Specify the area of your back where you have experienced pain by selecting from options: Neck (cervical), Middle (thoracic), or Low (lumbosacral).
If applicable, indicate whether the pain travels to other areas of your body and provide specific locations if you answered 'Yes'.
Detail the cause of your pain, including whether it was work-related, and provide any relevant treatment history.
Respond to questions about previous medical investigations, surgeries, hospitalizations, or disabilities related to back discomfort.
If you answered 'Yes' to any previous questions, provide additional details in the designated section.
Complete the declaration section by signing and dating it before submitting your form.

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