1. Where are you currently experiencing pain?
Please check appropriate boxes:
lower back
leg
foot
neck
shoulder
arm

2. How long have you had this pain?
Please check appropriate box:
1-3 months
4-6 months
7-12 months
More than a year

3. Have you received a diagnosis from a physician for one of the following conditions: herniated disc, ruptured or bulging disc, degenerative disc disease, sciatica, pinched nerve, stenosis, or facet syndrome?
Yes     No

If Yes, which one(s):
Please check appropriate boxes:
herniated disc
ruptured or bulging disc
degenerative disc disease
pinched nerve
sciatica
spinal stenosis
facet syndrome

4. When was your most recent MRI or CT scan?
within the last 3 months
4 to 12 months ago
more than 1 year, but less than 2 years
over two years ago
haven't had one

5. Have you received Chiropractic, Physical Therapy, or spinal injections for your condition?
Yes     No

6. Have you had low back or neck surgery
Yes     No

6a. If yes, what type of surgery:
laminectomy
discectomy
fusion
other

6b. If yes above, do you have any hardware in your back like screws, rods or plates?
Yes     No

7. Have you been told that you might need spine surgery?
Yes     No

8. Have you been told You might just have to live with some pain.?
Yes     No

9. Do you have trouble doing daily activities such as walking, sleeping, bending?
Yes     No

10. Are you pregnant?
Yes     No

11. Do you have any congenital defects of the spine?
Yes     No

12. Do you have pelvis cancer?
Yes     No

13. Have you been diagnosed with severe osteoporosis?
Yes     No

14. Have you had an aortic aneurysm?
Yes     No

15. Are you on blood thinners?
Yes     No

16. Anything else you would like to add?

Name
Email address
Phone #
Your Zip Code