Online Consultation for Spinal Decompression Therapy treatment program. Northstar Spinal Decompression Therapy. Non surgical non invasive treatment for back pain. A Division of Northstar Chiropractic Natural Wellness Center. 630-795-1889. Dr. Paul Reiselman BSN, RN, MA, DC, DiHom. Serving Chicago and the Western Suburbs. Treatment programs for bulging disc, neck pain, lower back pain, accident injury, personal injury, spinal stenosis, herniated discs, degenerative disc disease, sciatica, bulging disc.

Online Consultation

The Online consultation questionnaire is not meant for a diagnosis or prognosis. If you have a medical condition that requires immediate attention don’t hesitate to contact your doctor. This form is not an implied acceptance or in any other manner acceptance of you as a patient for care, but rather a means for educational purposes.

This online questionnaire is designed to provide initial answers to common questions that maybe asked during a consultation regarding one’s condition. After answering the questions they will be submitted to see if your condition may be treated using a non-surgical means for conditions of the spine that have been a nuisance for many years. Over 120 million people suffer with chronic back and neck pain, and the most common ways are treating the symptoms are with strong medication or invasive procedures. Most of the time this just masks the symptoms that will later cause more extreme measures of treatment. Many people do not know where to turn to, or who to trust. If there is a way to help you we use this form to see if we can help, if we cannot then we will help in the direction of what may be the best direction for you.

1. Please check the area(s) where you are experiencing pain:

	Buttock		Calf		Foot		Hip
	Leg		Low Back		Neck		Toes

2. How long have you been experiencing the pain?

	Less than a month		More than 6 weeks
	More than 6 months		More than 1 year

3. Which of the following best describe your pain?

	Burning		Dull/Ache		Numbness		Sharp
	Shooting		Throbbing		Tingling		Radiating

4. How often are you experiencing pain throughout the day?

	Intermittent (0-25% of the day)		Occasional (26-50% of the day)
	Frequent (51-75% of the day)		Constant (76-100% of the day)

5. Have you previously contacted another doctor about your pain?

Yes	No

	Other

6. Have you had neck or back surgery?

Yes

7. Have you been scheduled for surgery?

Yes

8. Check any of the following conditions you've been diagnosed with?

Degenerationn	Disc Herniation	Disc Bulge
Facet Syndrome	Stenosis	Sciatica
Spondylolisthesis	Other

9. My condition and pain has affected my activities as follows:

Decreased Activities	Decreased Concentration	Decreased Pace
Interrupted Sleep	Pain Standing	Pain Sitting
Trouble Lifting	Trouble Driving	Trouble Walking

10. The pain is aggravated by:

Arising	Bending backward	Bending forward
Coughing	Lying on Back	Pulling
Pushing	Straining	Twisting

11. Throughout the day when is the pain the worse? AM PM

12. How has your condition affected your life?

13. If there is a way to relieve your pain, are you interested in scheduling a consultation with the doctor?

Yes

14. Would you like information on the next upcoming workshop?

Yes

15. How did you hear about us?

16. Patient Information

Name:
Email:
Phone:
Address:
City:
Zip:

17. What time of the day is the best to contact you?

Any additional comments or concerns we could assist you with?

We will make every effort to respond within one business day.

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