| 1. Have you received a diagnosis from a physician for one of the following conditions: Herniated Disc, Ruptured Disc, Bulging Disc, Degenerative Disc, Sciatic Pain, Pinched Nerves, or Facet Syndrome? |
Yes No |
| 2. Have you received Chiropractic or Physical Therapy for your condition? |
Yes No |
| 3. Are you still experiencing Low Back Pain? |
Yes No |
| 4. Have you had Low Back Surgery? |
Yes No |
4a. If yes, What type of surgery?
Lamenectomy Discectomy Fusion |
4b. If yes, Did your surgery involve implementation of hardware installation such as Rods or Screws?
YES NO |
5. How Long have your experienced back pain?
0-30 days 2-3 mos. 3-6 mos. 6-12 mos. 12+ mos. |
| 6. Does you pain keep you from doing activities such as walking, sleeping, bending? |
Yes No |
| 7. Are you currently taking pain medication? |
Yes No |
| 8. If so, do you experience pain despite taking pain medication? |
Yes No |
| 9. Are you pregnant? |
Yes No |
| 10. Do you have any congenital defects of the spine? |
Yes No |
| 11. Do you have pelvis cancer? |
Yes No |
| 12. Have you been diagnosis with Severe Osteoporosis? |
Yes No |
| 13. What is your zip code? |
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