Survey

Your Name (required)

Your Email (required)

What is Your Occupation?

In Which Areas Are you Experiencing Pain?

Lower Back
Neck
Hips
Calf
Foot
Shoulder
Upper Arm
Lower Arm
Wrist
Hand
Fingers

Have You Experienced Any of the Following in the Last 6 Months?

Headaches
Dizziness
Arm or Hand Pain
Numbness and Tingling in Extremities
Pain Between Shoulders
Low Back Pain
Pain Down the Legs
Allergies or Asthma
Painful and stiff joints

Please Answer the Following Questions About the Pain You Are Experiencing.

Do you believe that your pain is getting worse?
Does your pain slow you down or stop you from performing daily activities?
Does your pain cause you to take medication more often for pain?
Does your pain cause you to miss work?
Does your pain make you think about having surgery?
Are you scared of the outcome of surgery?

Please Describe The Frequency of Your Symptoms

Intermittent | Occasional | Frequent | Constant

Have You Ever Visited Any of the Following?

Primary Doctor
Neurologist
Orthopedic Specialist
Chiropractic
Acupuncture
Physical Therapist
Massage Care

Do You Have Access to Any Current Imaging?
CAT ScanMRIXray

Have You Ever Had Back Surgery?YesNo

Have You Ever Had Neck Surgery?YesNo

If you do qualify as a non-surgical disc decompression candidate and there was a way to help relieve your pain using one of our advanced non-surgical treatment programs, would you be willing to schedule a consultation?
YesNo

If so, When is the best time to contact you?
MorningAfternoonEvening