*
These fields are necessary to complete the form.
Name
:*
Email
:*
Day Time Phone
:*
Evening Phone
:
Where is the pain located?
Neck (Cervical)
Back (Lumbar)
Rate your pain from 1-10 for the Average for the last week. (Example: 6/10):
Average:
1
2
3
4
5
6
7
8
9
10
Most
:
1
2
3
4
5
6
7
8
9
10
Least
:
1
2
3
4
5
6
7
8
9
10
Do you have weakness, tingling or burning pain into any extremity due to certain positions?
Right Arm
Right Hand
Right Fingers
Left Arm
Left Hand
Left Finger
Right Hip
Right Leg
Right Calf
Right Foot
Right Toe(s)
Left Hip
Left Leg
Left Calf
Left Foot
Left Toe(s)
What have you done to relieve the pain in the past?
Physical Therapy
Accupuncture
Chiropractic
Massage Therapy
Exercise Rx
Other
Are currently on any medication for the pain?
Loratab
Morphine
Flexerill
Other
Hydrocodine/Codone
None
What surgeries have you had in relation to the pain? (Spinal related only)
Laminectomy
Discectomy, Spinal Fusion
Percutaneous Laser Disc Decompression
IDET
Other
None
What X-Rays, MRI's, CT Scans, etc. have you most recently had?
X-Rays
Discogram
MRI
Other
CT Scan
Are you female and over fifty years of age?
Yes
No
If yes, have you had a recent (DEXA) bone scan?
Yes
No
How did you hear about Spina Health Inc?
News
Local Newspaper
Magazine
Doctor
Internet
Friend
Radio
Other
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