Claim your $43 New Patient Spinal Decompression Consultation!

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Spinal Decompression Protocol Survey

Before we begin, please provide your contact information.

If you are a good candidate, someone from our team will contact you within one business day.

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Spinal Decompression Protocol Survey

Which of the following symptoms are you currently experiencing?  

Please select all that apply.

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Spinal Decompression Protocol Survey

Where is your pain located?

Please select all that apply.

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Spinal Decompression Protocol Survey

Have you had any previous imaging done?

Please select all that apply.

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Spinal Decompression Protocol Survey

Have you been diagnosed with the following condition(s):

Please select all that apply.

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Spinal Decompression Protocol Survey

Duration of Condition:

How long have you been experiencing your symptoms?

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Spinal Decompression Protocol Survey

Severity of Condition:

On a scale of 1-10 How would you rate the severity of your symptoms?

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Spinal Decompression Protocol Survey

Previous Treatments:

What have you done in the past to treat your pain?

Please select all that apply.

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Spinal Decompression Protocol Survey

On a Scale of 1 – 10 with 1 being the lowest level of success and 10 being the highest, How well have you been able to manage your symptoms with your past treatments?

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Spinal Decompression Protocol Survey

Treatment Goals and Expectations:

What are your primary goals and expectations from this treatment?

Please select all that apply.

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Spinal Decompression Protocol Survey

What day of the week is the best for someone on our staff to contact you?  

Please select all that apply.

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Spinal Decompression Protocol Survey

What time of day is the best for someone on our staff to contact you?  

Please select all that apply.

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Spinal Decompression Protocol Survey

Comments and concerns:

Is there any additional information you would like to share with the Doctor before we contact you?

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