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 :