1. Are you currently experiencing neck or back pain?

Yes

No

2. Does the pain radiate into your hip, buttock or leg? Does it radiate into your shoulder, arm or hand?

Yes

No

3. Do you have numbness or tingling in your leg/foot or your arm/hand?

Yes

No

4. Have you had these symptoms for more than three months?

Yes

No

5. Have you been diagnosed with any of the following:

Slipped, Herniated or Bulging Disc

Slipped, Herniated or Bulging Disc

Spinal Stenosis

Degenerative Disc Disease

Facet Syndrome

Failed Back Surgery

Spondylolisthesis

6. Have any of the following treatments been unsuccessful:

Over-The-Counter Medications

Prescription Medications

Chiropractic Adjustments

Physical Rehabilitation Therapy

Epidural Steroid Injections

Acupuncture

Inversion Therapy

Spine Surgery

7. Because of Pain do you:

Stay home more of the time/get out less?

Limit your work or household chores?

Restrict your family and recreational activities?

If you have answered “Yes” to multiple questions, then you may be a good candidate for treatment. Fill out this form to schedule your New Patient Special.

Full Name

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