Drummond-Iphone-survey

Please complete the questionaire below. Any further questions or to see if you qualify by phone, please call our office at 402-452-3400

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
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
First Name:	*
Last Name:	*
Address:	*
City:	*
State:	*
Zip:	*
Phone:	*