Non-Surgical Spinal Decompression Prequalification Questionnaire

230 California Street, Suite 600 • Downtown San Francisco • (415) 627-9077

• Satellite Offices in Union Square and San Ramon, CA

Dan W. Perez, DC - Clinic Director

Non-Surgical Spinal Decompression
Pre-Qualification Questionnaire

First Name:
Last Name:
Age:
Sex:	Male Female
Check the symptoms you have experienced within the last six (6) months:	Low Back Pain Buttock Pain Sciatica (leg pain) Back Spasms Back Stiffness Leg Weakness Leg Numbness Leg Muscle Atrophy Pins and Needles Foot Drop Hurts to Raise Leg
How did your pain come about?:	Lifted something heavy Fall or accident Sports injury No particular event Don't know
How long have you had this pain? (years, months):
Does coughing hard make your back hurt more?:	Yes No
Check the types of treatment you have received thus far for your condition:	Chiropractic Physical Therapy Acupuncture Pain Medications Cortisone Injections Lidocaine Injections Back Exercises Other
What treatment did you find gave you the most relief?:
Are you currently under the care of a physician for your back problem?:	Yes No
Have you had spinal surgery?:	Yes No
If so, when (date)?:
List procedures done on you:	Laminectomy Discectomy Spinal fusion Percutaneous Laser Neurotomy Pedicle screws X-Stop device Artificial disc Spinal rods Other
Have you had an MRI taken of your spine?:	Yes No
Do you have recent X-rays of your spine?:	Yes No
Has an orthopedic surgeon or other doctor ever given you a diagnosis, such as disc herniation? If so, please describe:
Please indicate if you have any of the following conditions:	Osteoporosis Rheumatoid Arthritis(RA) Ankylosing Spondylitis Congenital fusion Aortic aneurysm Heart surgery Pacemaker Spondylolisthesis Recent Fracture or Injury Pregnancy Cancer Lupus
Would you like your questionnaire results emailed or phoned to you:	emailed phoned
Daytime Phone Number:
Email:

Suffering from chronic low back pain due to degenerative discs?

Take our Spinal Decompression

Pre-Qualification Questionnaire

and find out if you are a candidate for this treatment.

Chiropractic Wellness Care:

Start Feeling Better Today!
(click the image)

Non-Surgical Spinal Decompression Pre-Qualification Questionnaire

Non-Surgical Spinal Decompression
Pre-Qualification Questionnaire