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This is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you. Please fill out this questionnaire.

Name   *
Email   *
Address
City
State   *
Zip Code
Phone Number   *
Best time for us to call you
Are you the Patient?    If no, please tell us
Areas of Difficulty
Has patient had spine surgery?
What was done? When was it? Who was the surgeon?
Do you have Back Pain?
Do you have Leg Pain?
Do you have Leg Numbness?
Do you have Leg Weakness?
Which Leg is worse overall?
Any bowel, bladder or sexual difficulty?   *
If Yes, please describe below.
Do you need any assistance to walk (cane, crutch, wheelchair)?   *
If Yes, please describe below.
Patient's Age (MM/DD/YYYY)
Patient's Sex
Patient's Height
Patient's Weight
Please tell us your exact symptoms:
(back pain? leg pain? weakness? numbness? exactly where)
Describe patient's problem
The problem started when?
Have you had chiropractic treatments?
Has patient seen a surgeon for a present problem? What was recommended?
What tests and treatment has patient had?
What medication are you taking and how often?
Where and when did you have your latest MRI scan?
Are you going to have your MRI scan report faxed to our national receiving fax at 310-659-8869?
(Attn: Dr. David Ditsworth, Chief of Neurosurgery)
Describe your usual sport activities before your spine problem:
Are you able to do any sport activity now? Describe:
Do you or did you stress your back in your work?
Describe your work?
Job Title now (or when you were working)
Where did you hear about us

   If Others,
What would you like to ask us?
Insurance Company Name
Insurance Type
Consent:    *