Are-you-a-spinal-decompression-candidate

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Are-you-a-spinal-decompression-candidate adminspinal 2018-02-19T19:06:36+00:00

Please complete the questionaire below. Any further questions or to see if you qualify by phone, please call our office at 604-984-4601

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

Neck
Low Back
Buttocks
Leg
Hip
Calf
Foot

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

Yes
No

My condition and pain has affected my activities as follows

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

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If you are suffering from Chronic Low Back and Neck Pain, ciatica, a Herniated Disc, Bulging Disc, Spinal Stenosis, or Pinched Nerve… We now the solution.

Spinal Decompression Therapy
Cold Laser Therapy
Active Release Therapy
Chiropractic Care
Shockwave Therapy

Don’t Spent Another Day in Pain

Pick up the phone and give us a call!
206 – 168 East 13th Street
North Vancouver, British Columbia V7L 4W8
Phone: 604-984-4601
info@vanspinaldecompression.com