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

No

7. Have you been scheduled for surgery?


Yes

No


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


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

No


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


Yes

No


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.