Please Note: Only fill out this form if you are ready and willing to have a complimentary consultation with an approved doctor. Please check all spam and email filters for our emails and it is always best to leave a good contact number. Web Physician Consultation is used to determine if you are a candidate for this revolutionary technology called Non-Surgical Spinal Decompression Therapy. This will also be used to schedule a consultation with the doctor if you so choose. This is not meant to give you a diagnosis or prognosis. The Web Physician Consultation is for educational purposes only. Please check ALL that apply.

Where is your symptom(s) located?

Neck Fingers Hip Calf   Arm Low Back Thigh Foot   Wrist Buttocks Leg Toes

Which best describes your pain?

Dull Pain Sharp Pain Throbbing Pain Tingling   Achy Pain Shooting Pain Burning Pain Numbness

How long have you had the pain?

Four weeks or less More than six months   Five weeks or more More than one year

What is the frequency of your symptoms?

Intermittent 0-25% of the day Frequent 51-75% of the day   Occasional 26-50% of the day Constant 76-100% of the day

The Pain is worse in the:

AM   PM   Both

Have you already contacted a doctor for this complaint?

Yes No

Have you been diagnosed with any of the following?

Herniated Disc Degenerative Disc Disease   Bulging Disc Stenosis   Sciatica Spondylolisthesis

Have you been clinically diagnosed with any of the following?

Osteoporosis Cancer   High Cholesterol Heart Disease   High Cholesterol Heart Disease   High Blood Pressure Stroke   Diabetes Abdominal Aortic Aneurysm

Have you had an MRI or CT?

Less than one year ago Two or more years ago   Less than two years ago I have not had an MRI or CT

Did you have Neck or Back surgery?

Yes No

If yes, was there metal of any kind left in your spine? (For example: screws, plates, rods, etc.)

Yes No

Are you scheduled for Neck or Back surgery?

Yes No

My Pain and or Condition has affected these activities:

Sitting Laying on Back Walking Physical Activities   Standing Sleeping Lifting Lack of Concentration   Sitting to Standing Driving Pushing None

My Pain and or Condition is aggravated by:

Bending Forward Twisting Right Coughing Bearing down while moving bowels   Bending Backward Twisting Left Sneezing Numbness

When the pain is at its worse, please describe how you feel and how it affects you.

Have you been given a poor prognosis?

Yes No

Have you been told you need to live with the pain?

Yes No

When was the last time you were free from pain or discomfort?

Within One month More than One year ago   More than One month ago More than Five years ago   More than Six months ago More then Ten years ago

If there is possibly a way to relieve your condition or pain with Non-Surgical and Non-Invasive Spinal Decompression, are you interested in scheduling a consultation with the doctor?

Yes No

When is the best time to contact you to schedule a consult with the doctor?

Morning Evening   Afternoon

Name :   Age :   Email :   Phone :   Address :   City :   State :   Zip :