Complete the below survey and we will let you know if you can be a candidate For Non-Surgical Spinal Decompression Please check any or all of the primary pain you are experiencing: NeckLow BackButtocksHipLegCalfFoot/Toes How long have you had the pain? Less than a monthMore than 6 wksMore than 6 monthsMore than 1 yr Check any or all of the modifiers that most closely describe your pain. DullSharpBurningTinglingShootingNumbnessThrobbing Which best describes the frequency of your pain? Intermittent (0–25% of day)Occasional (26–50% of day)Frequent (51–75% of day)Constant (76–100% of day) Have you already contacted a doctor about your pain YESNO Have you had back surgery? YESNO Are you scheduled for back surgery? YESNO Have you been diagnosed with any of the following Disc HerniationDisc BulgeSciaticaSpinal StenosisDisc DegenerationSpondylolisthesis My condition and pain has affected my activities as follows Pain SittingPain StandingTrouble WalkingInterrupted Sleep at nightDecreased ActivitiesDecreased Pace Which more closely describes your pain level by time of day: AMPM When is your pain at its worst? Describe how you feel and are affected: When was the last time you felt really great? If there is a way to relieve your pain with one of our advanced non-surgical treatment programs, are you interested in scheduling a consult with our doctor? YESNO What is the best time to contact you? MorningAfternoonEvening Name: Phone: *
