First Name *

Last Name *

Email *

Phone *

How Bad Does Your Pain Get on a a Scale of 1-10?

How Long Have You Had This Pain?

Where is Your Pain Worst?

Mid Back Pain (Thoracic Spine)

Lower Back Pain (Lumbar Spine)

Neck Pain (Cervical Spine)

Legs (thigh, calf, foot)

Buttocks

Hip

Arm (shoulder, upper arm, forearm, hand)

Other

Insight: Pinpointing pain location helps identify potential spinal regions of concern, as disc issues often refer pain to specific areas.

How would you describe the sensation of your pain? (check all that apply)

Dull ache

Sharp/stabbing

Burning

Tingling

Numbness

Radiating/shooting

Cramping

Weakness

Other

Does your pain limit the time you can:

Sit

Stand

Lie down

During the Past 12 Months:

Different pain descriptors can indicate nerve involvement (tingling, numbness, radiating), inflammation (burning, sharp), or muscle spasm (cramping, dull ache). Limitations in standing are very often associated with intervertebral disc issues, especially degenerative disc disease or discogenic pain.

Have you had an MRI in the last 12 months?

Yes

Have you been diagnosed with any of the following spinal conditions? (check all that apply, if known)

Degenerative Disc Disease

Bulging Disc

Herniated Disc

Sciatica

Radiculopathy (nerve pain in arms/legs)

Spinal Stenosis

None of the above

Not sure - have not been formally diagnosed

Which Treatments Have you Tried?

Rest

Physical Therapy

Pain Medication

Injections

Surgery

Insight: Understanding prior treatments helps gauge the chronicity and severity of the condition, as well as indicating whether conservative measures have been successful.

Any message you'd like to include:

By checking this box, I acknowledge that I am requesting information about the Discseel procedure from Biologic Spine Therapy and consent to be contacted by them via the email address or phone number I have provided.