Discover Your Path to Pain Relief

Take Our Quick Pain Screening Quiz to Find Out If Minimally Invasive Spine Treatment is Right for You.

First Name *

Last Name *

Phone *

Email *

Where is your pain? *

Lumber (Lower Back)

Thoraic (Mid Back)

Foot

Head

Shoulder

Hip

Knee

Cervical (Neck)

Have you been diagnosed with any of the following? *

Herniated/Bulging Disc or Annular Tear

Degenerative Disc Disease (DDD)

Stenosis

Sciatica

Radiculopathy

Pinched Nerve

Facet Joint Syndrome

Bone Spurs/Osteophytes

Spondylosis

Other

How would you describe your pain? *

Shooting Pain

Burning

Cramping

Throbbing

Sharp

Other

Do you have any associated symptoms? *

Pins

Needles

Numbness

Weakness

Tingling

Other

Where is the pain worst? *

Neck

Lower back

Middle back

Upper back

Right Arm

Left Arm

Both Arms

Right Leg

Left Leg

Both Legs

How did your pain start? *

Work related

Motor Vehicle Injury

Personal Injury

Other

What triggers your pain? *

Sitting

Standing

Walking

Laying Down

Bending Forward

Bending Backward

Other

What improves or alleviates your pain? *

Sitting

Standing

Walking

Laying Down

Bending Forward

Bending Backward

Other

What tests have you had? *

CT Scan

MRI

XRay

Other

What treatments have you had for the pain? *

Chiropractic Treatment

Physical Therapy

Acupuncture

Spinal Injections

Spine Surgery

Other

Insurance

Private

Medicare

Medicare +Supp

Auto Accident/Personal Injury

Work Comp

Self Pay

None

Type of Insurance *

HMO

PPO

POS

Other

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