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 *

Name of Spouse

stopped Best Have

Email *

Address

City *

State *

Zip Code

Phone Number *

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

• Cervical - Neck
• Other

Has patient had spine surgery?

• Yes
• No

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

Any bowel, bladder or sexual difficulty?

• Yes
• No

If Yes, please describe below

Do you need any assistance to walk (cane, crutch, wheelchair)?

• Yes
• No

If Yes, please describe below

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

Patient's Sex

Height

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?

• 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?

• Yes
• No

Describe your recent 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?

• 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?

Please write down what you're curious about and what you'd like to ask here if possible, as it will be a great help for us to know what kind of assistance you need.

Are you taking any medication for weight loss or diabetes? Please list:

What medication are you taking and how often?

If you are on anti-coagulant medication, please tell us how long you have taken it and if you have stopped it to have a procedure in the past

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.

Please solve a simple question to confirm that you are human. (The answer must be written as a number) *

How many legs does a typical cat have?

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