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Spinal Decompression Candidate Questionnaire
Please complete this form.
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Name
*
First
Last
Birth Date (mm/dd/yyyy)
Email
*
Sex
*
Male
Female
Are You Experiencing any of the following?
*
Chronic Neck Pain
Radiating Arm Pain
Numbness and/or tingling in arm, hand or fingers
Disc bulge or herniation in cervical spine (neck)
Spinal stenosis in cervical spine (neck)
Arthritis in cervical spine (neck)
Chronic Lower Back Pain
Radiating Leg Pain
Spinal stenosis in lumbar support (lower back)
Disc bulge or herniation in lumbar support (lower back)
Arthritis in lumbar spine (lower back)
Radiating leg pain / sciatica" "Numbness and / or tingling in legs, heel or foot
Have you had lower back or neck surgery before?
*
Lower Back
Neck
Both
Neither
Which of your activities of daily living are affected the most?
*
Driving
Sleeping
Standing
Walking
Lifting
Exercising
Socializing
Traveling
Intimacy
Playing with Children
Other
What Result do you want most for yourself?
*
Pain Reduction
Restore quality of life
Restore optimum health
Avoid surgery
Avoid medication
Other?
What types of treatment have you already tried?
*
Pain medication
Physiotherapy
Chiropractic
Acupuncture
Massage therapy
Spinal injections
Surgery
Excercise therapy
Personal trainer
Aquatherapy
Other?
When was your most recent MRI/Xray? (mm/dd/yyyy)
*
Rate your pain level today? (1 - 5)
Selected Value:
1
How many years have you been suffering with this pain?
*
How important is your quality of life? (1 - 5)
Selected Value:
1
If you would like to be contacted by Community Chiropractic Centre to book a no-charge consultation with Dr. Sarah Dale or Dr. Todd Small please indicate what time of day would be the best time to call and what phone number you would like to be contacted at?
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