Progress Bar - 10 Percent Complete

STEP 1:
TELL US ABOUT YOUR PAIN

Choose all that apply:

Lower Back

Middle Back

Neck

Shoulders

Arms

Buttocks

Legs

Other

If other, please explain:
Where is the pain strongest?
How long have you been experiencing pain?
Have you been diagnosed with a specific condition?

STEP 2:
DESCRIBE YOUR PAIN FOR US

How would your describe your pain?
Are you always in pain?
Do you have any of the following symptoms?

Pins and Needles Feeling

Numbness

Tingling Sensations

Progressing Weakness

Loss of Coordination

None

STEP 3:
TELL US MORE ABOUT YOUR SYMPTOMS

When is your pain at its worst? Choose all that apply.
When does your pain feel better?
What caused your pain originally?
If other, please explain:

STEP 4:
TELL US ABOUT YOUR PAST TREATMENT

Have you undergone any of the following?

CT Scan

MRI

X-ray

Nerve Conduction Study

Other

None

If other, please explain:

STEP 5:
GET YOUR RESULTS NOW

Insurance
OK, Which One?
Best time to call
Comments

STEP 2:
TELL US ABOUT YOUR CONDITION

What condition do you have?

Bulging Disc

Coccydynia

Disc Degeneration

Disc Tear

Facet Joint Disease

Failed Surgery

Foraminal Stenosis

Herniated Disc

Lower Back Pain

Pinched Nerve

Radiculopathy

Sacroilitis

Sciatic Nerve

Bone Spurs

Spinal Stenosis

Spondylolisthesis

STEP 3:
TELL US ABOUT ANY RECENT TREATMENTS

Have you undergone any of the following?

CT Scan

MRI

X-ray

Nerve Conduction Study

Other

None

If other, please explain:
How long ago was your last Ct Scan, MRI, X Ray, or Nerve Condition Study?
Are you currently undergoing any treatment?
If yes, which treatments?

Medication

Chiropractor

Acupuncture

Physical Therapy

Nerve Block Injections

Cortisone Injections

Other

None

If other, please explain:

STEP 4:
TELL US HOW EFFECTIVE YOUR TREATMENTS ARE

How effective is your current treatment?
What other treatments have you undergone?

Medication

Chiropractor

Acupuncture

Physical Therapy

Nerve Block Injections

Cortisone Injections

Other

None

If other, please explain: