question

Initial Inquiry Form

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

Name *

Email Address *

Address

City

State *

Zip Code

Phone Number *

Best time for us to call you

Areas of Difficulty

Has patient had spine surgery?

What was done? When was it? Who was the surgeon?

Patient's Age (MM/DD/YYYY)

Patient's Sex

Patient Height

Patient Weight

Do you have neck pain, arm pain, numbness, weakness?

Describe patient's problem. Exactly where?

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?

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?

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 neck in your work?

Describe your work?

Job Title now (or when you were working)

Where did you hear about us

What would you like to ask us? *

Insurance Company Name

Insurance Type

By submitting this form, I give consent for the Back Institute to share my medical records with outside spine experts to get additional opinion.

Submit

Thank you! Your message has been sent.

Unable to send your message. Please fix errors then try again.