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

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Name (Required) *

Email (Required) *

Address

City (Required) *

State (Required) *

Zip Code

Phone Number (Required) *

Best time for us to call you

• Any Time
• 1st Half of the Day
• 2nd Half of the Day

Are you the Patient? If no, please tell us

Areas of Difficulty

• Low Back
• Mid Back
• Knee
• Other

Has patient had spine surgery?

• Yes
• No

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

Do you have Back Pain?

• Yes
• No

Do you have Leg Pain?

• Yes Right Leg
• Yes Left Leg
• Yes Both Legs (Equal Pain)
• Yes Both Legs (Not Equal Pain)
• No

Leg Numbness

• Yes Right Leg
• Yes Left Leg
• Yes Both Legs (Equal Numbness)
• Yes Both Legs (Not Equal Numbness)
• No

Leg Weakness

• Yes Right Leg
• Yes Left Leg
• Yes Both Legs (Equal Weakness)
• Yes Both Legs (Not Equal Weakness)
• No

Which Leg is worse overall?

• Right
• Left
• Can not tell

Patient's Date of Birth (MM/DD/YYYY)

Patient's Sex

Height

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?

• Yes
• No

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? (Attn: Dr. David Ditsworth, Chief of Neurosurgery)

• Yes
• No

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?

• Yes
• No

Describe your work?

Job Title now (or when you were working)

Where did you hear about usSelect OneYoutubeGoogle_SearchBing_SearchNY_TimesYahoo_SearchTwitter, now XOther

What would you like to ask us?

What medication are you taking and how often?

If you have a google account, enter your google email address

Insurance Company Name

Insurance TypeSelect OnePPOPOSHMOMedicareAuto InsuranceAffordable Cared ActOtherNo Insurance

CONSENT (REQUIRED) *

• By submitting this form, I give consent for the Back Institute to share my medical records with outside endoscopic experts to get additional opinion and for them to contact me, understanding that "NANO" endoscopic is not available elsewhere.

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