Complete the below survey and we will let you know if you can be a candidate For Non-Surgical Spinal DecompressionPlease check any or all of the primary pain you are experiencing:NeckLow BackButtocksHipLegCalfFoot/ToesHow long have you had the pain?Less than a monthMore than 6 wksMore than 6 monthsMore than 1 yrCheck any or all of the modifiers that most closely describe your pain.DullSharpBurningTinglingShootingNumbnessThrobbingWhich 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 painYESNOHave you had back surgery?YESNOAre you scheduled for back surgery?YESNOHave you been diagnosed with any of the followingDisc HerniationDisc BulgeSciaticaSpinal StenosisDisc DegenerationSpondylolisthesisMy condition and pain has affected my activities as followsPain SittingPain StandingTrouble WalkingInterrupted Sleep at nightDecreased ActivitiesDecreased PaceWhich more closely describes your pain level by time of day:AMPMWhen 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?YESNOWhat is the best time to contact you?MorningAfternoonEveningName:Phone: *