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 FREE consultation and find the relief you’ve been searching for!
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