What condition(s) do you have?
Bulging Disc
Degenerative Disc Disease
Disc Tear
Facet Joint Disease
Failed Fusion Surgery
Failed Surgery Syndrome
Foraminal Stenosis
Herniated Disc
Pinched Nerve
Radiculitis
Radiculopathy
Sciatica
Spinal Bone Spurs
Spinal Stenosis
Spondylolisthesis
Other
Please explain your condition further, if necessary.
How long have you been experiencing pain?
1 month or less
1 - 6 months
7 - 12 months
1 year or more
Have you undergone any of the following treatments?
CT Scan
MRI
Myelogram
Viscogram
X-Ray
Nerve Conduction Study
Other (Please Explain)
None
Have you undergone any of the following treatments (other)?
How long ago was your last treatment done?
1 Month or less
1 - 6 Months
7 - 12 Months
1 Year or more
What non-surgical treatments have you tried?
Medication
Chiropractic Care
Massage
Acupuncture
Epidurals
Physical Therapy
Nerve Block Injections
Cortisone Injections
Other
None
How effective is your current treatment?
Not Very
Somewhat
Very
How long does the treatment help with your pain?
1 - 7 Days
2 - 4 Weeks
2 - 3 Months
3 - 6 Months
6 - 12 Months
More Than One Year
Have you been recommended for a specific treatment you have not yet undergone?
EMG
Viscogram
Medication
Chiropractor
Acupuncture
Physical Therapy
Nerve Study
Nerve Block Injections
Cortisone Injections
Other
None
Have you been recommended for a specific treatment you have not yet undergone (other)?
First Name
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Last Name
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Email
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Phone
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How Can We Help?
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Spine
Orthopedic
Pain Management
Bariatric
Cosmetic
Gynecology
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Insurance Type
HMO
PPO
LOP
PIP
Worker's Comp
Medicare
Medicaid
Self-pay
Other
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Additional Comments
SUBMIT
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