Fantasia-survey

Please check any or all of the primary pain you are experiencing:

Neck Low Back Buttocks Hip Leg Calf Foot Toes

How long have you had the pain?

Less than a month More than 6 wks More than 6 months More than 1 yr

Check any or all of the modifiers that most closely describe your pain.

Dull Sharp Burning Tingling Shooting Numbness Throbbing

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

YES NO

Have you had back surgery?

YES NO

Are you scheduled for back surgery?

YES NO

Have you been diagnosed with any of the following

Disc Herniation Disc Bulge Sciatica Spinal Stenosis Disc Degeneration Spondylolisthesis

My condition and pain has affected my activities as follows

Pain Sitting Pain Standing Trouble Walking Interrupted Sleep at night Decreased Activities Decreased Pace

Which more closely describes your pain level by time of day:

AM PM

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?

YES NO

What is the best time to contact you?:

Morning Afternoon Evening

Name:

Phone:

*

Complete the below survey and we will let you know if you can be a candidate For Non-Surgical Spinal Decompression