First Name: *

Last Name: *

Address:

City:

State: Please select a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Preferred contact method (Select all that apply): Home Phone
Work Phone
Cell Phone
Email
*

Home Phone: *

Work Phone: *

Cell Phone: *

Email: *

What is/are the location(s) of your problem? Neck
Mid Back
Low Back
Arm(s)
Leg(s)

What type of symptom(s) are you experiencing? Pain
Numbness
Weakness
Tingling

What is the severity of your pain? Please select Mild Moderate Severe (worst pain) Incapacitating

How long have you had this pain? Please select Less than a month 1 - 6 months 6 months - 1 year 1 - 3 years More than 3 years

Have you seen a physician for this pain? Yes No

Have you had any of the following medical tests? (Must bring BOTH CDs and reports): None
X-Ray
CT Scan
MRI
Myelogram
Discogram
*

When was the test taken: *

What diagnosis were you given? Herniated Disc
Stenosis
Degenerative Disc
Strain/Sprain
Scoliosis
Kyphosis
Bulging Disc
Compression Fracture
Sciatica
Don't Know
None Given
*

Other Diagnosis:

If you have Scoliosis what is your Degree of Curve?

Have you had any of the following treatments for your back? (Check all that apply): None
Physical Therapy
Medication
Manipulation
Injections
Surgery
Other
*

If you had spine surgery, what type? (Check all that appy): Spine Fusion
Discectomy
Laminectomy
IDET
Disc Replacement
Other

If injured, what was the cause of your injury? Accident at Work
Motor Vehicle Accident
Other

Has surgery been recommended for your problem? Yes No

By Whom?

If there was a surgical solution to your problem, would you consider surgery? Yes No

Describe your back problem:

Age: *

Gender: Male Female *

Referred by: Other Physician
Patient/Friend
Radio
TV News
Newspaper
Internet
Other
*

If other, please specify:

Preferred physician: Please select Bulkin Casden Kahn Kuflik Lee Neuwirth Roonprapunt No Preference *

Physician chosen:

Also Email:

Insurance Name: *

Policy Number: *

Primary insurance type: Please select PPO POS HMO Workers Comp Auto Insurance Other *

Other Insurance:

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