SPINAL DECOMPRESSION QUESTIONNAIRE



Non-Surgical Spinal Decompression
Pre-Qualification Questionnaire

First Name:
Last Name:
Age:
Sex: Male
Female
Check the symptoms you have experienced within the last six (6) months: Low Back Pain
Buttock Pain
Sciatica (leg pain)
Back Spasms
Back Stiffness
Leg Weakness
Leg Numbness
Leg Muscle Atrophy
Pins and Needles
Foot Drop
Hurts to Raise Leg
How did your pain come about?: Lifted something heavy
Fall or accident
Sports injury
No particular event
Don't know
How long have you had this pain? (years, months):
Does coughing hard make your back hurt more?: Yes
No
Check the types of treatment you have received thus far for your condition: Chiropractic
Physical Therapy
Acupuncture
Pain Medications
Cortisone Injections
Lidocaine Injections
Back Exercises
Other
What treatment did you find gave you the most relief?:
Are you currently under the care of a physician for your back problem?: Yes
No
Have you had spinal surgery?: Yes
No
If so, when (date)?:
List procedures done on you: Laminectomy
Discectomy
Spinal fusion
Percutaneous Laser
Neurotomy
Pedicle screws
X-Stop device
Artificial disc
Spinal rods
Other
Have you had an MRI taken of your spine?: Yes
No
Do you have recent X-rays of your spine?: Yes
No
Has an orthopedic surgeon or other doctor ever given you a diagnosis, such as disc herniation? If so, please describe:
Please indicate if you have any of the following conditions: Osteoporosis
Rheumatoid Arthritis(RA)
Ankylosing Spondylitis
Congenital fusion
Aortic aneurysm
Heart surgery
Pacemaker
Spondylolisthesis
Recent Fracture or Injury
Pregnancy
Cancer
Lupus
Would you like your questionnaire results emailed or phoned to you: emailed
phoned
Daytime Phone Number:
Email:

To schedule an appointment, call (415) 627-9077 or use our self-service, online appointment scheduling application, Genbook.

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