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adminspinal
2018-02-19T19:06:36-08:00
Please complete the questionaire below. Any further questions or to see if you qualify by phone, please call our office at 604-984-4601
RM_Stats
Username
*
Password
*
Password must be at least 7 characters long.
Enter password again
*
Password must be at least 7 characters long.
Email
*
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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