{"id":120,"date":"2019-12-17T22:49:37","date_gmt":"2019-12-17T22:49:37","guid":{"rendered":"https:\/\/backinstituteneurosurgery.com\/web\/?page_id=120"},"modified":"2025-11-09T09:34:19","modified_gmt":"2025-11-09T09:34:19","slug":"new-patient-form","status":"publish","type":"page","link":"https:\/\/backinstituteneurosurgery.com\/main\/new-patient-form\/","title":{"rendered":"New Patient Form"},"content":{"rendered":"<p><strong>Initial Inquiry Form<\/strong><br \/>\nThis is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you. Please fill out this questionnaire<\/p>\n<div class=\"mobile-only-text\">\n<strong><\/p>\n<h2><FONT COLOR=\"RED\">Currently, our practice is not participating in any clinical trials.<\/FONT><\/h2>\n<p><\/strong><br \/>\n<strong><\/p>\n<h3>We have noticed that our advertisement may have appeared in search results for trials, which was unintended.<br \/>\n<\/h3>\n<p><\/strong>\n<\/div>\n<div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-904\"><form id=\"wpforms-form-904\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"904\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/main\/wp-json\/wp\/v2\/pages\/120\" data-token=\"355f5294ae75155d3b27308188fb7584\" data-token-time=\"1776005541\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#066aab\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"3\" tabindex=\"-1\"><span class=\"wpforms-page-indicator-page-title\" ><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> - <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 3<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:33.333333333333%;background-color:#066aab\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-904-field_61-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"61\"><\/div><div id=\"wpforms-904-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_0\">Name  (Required)  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-904-field_0\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][0]\" aria-errormessage=\"wpforms-904-field_0-error\" required><\/div><div id=\"wpforms-904-field_58-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_58\">Name of spouse<\/label><input type=\"text\" id=\"wpforms-904-field_58\" class=\"wpforms-field-medium\" name=\"wpforms[fields][58]\" aria-errormessage=\"wpforms-904-field_58-error\" ><\/div><div id=\"wpforms-904-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_1\">Email  (Required)  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-904-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" aria-errormessage=\"wpforms-904-field_1-error\" required><\/div><div id=\"wpforms-904-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_3\">Address<\/label><input type=\"text\" id=\"wpforms-904-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-904-field_3-error\" ><\/div><div id=\"wpforms-904-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_4\">City  (Required)  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-904-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-904-field_4-error\" required><\/div><div id=\"wpforms-904-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_5\">State  (Required)  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-904-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-904-field_5-error\" required><\/div><div id=\"wpforms-904-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_6\">Zip Code<\/label><input type=\"text\" id=\"wpforms-904-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-904-field_6-error\" ><\/div><div id=\"wpforms-904-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_7\">Phone Number  (Required)  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-904-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-904-field_7-error\" required><\/div><div id=\"wpforms-904-field_8-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"8\"><fieldset><legend class=\"wpforms-field-label\">Best time for us to call you<\/legend><ul id=\"wpforms-904-field_8\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_8_1\" name=\"wpforms[fields][8][]\" value=\"Any Time\" aria-errormessage=\"wpforms-904-field_8_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_8_1\">Any Time<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_8_2\" name=\"wpforms[fields][8][]\" value=\"1st Half of the Day\" aria-errormessage=\"wpforms-904-field_8_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_8_2\">1st Half of the Day<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_8_3\" name=\"wpforms[fields][8][]\" value=\"2nd Half of the Day\" aria-errormessage=\"wpforms-904-field_8_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_8_3\">2nd Half of the Day<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-904-field_36-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_36\">What is the primary question or concern you would like our assistance with? (Required) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-904-field_36\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][36]\" aria-errormessage=\"wpforms-904-field_36-error\" aria-describedby=\"wpforms-904-field_36-description\" required><\/textarea><div id=\"wpforms-904-field_36-description\" class=\"wpforms-field-description\">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.<\/div><\/div><div id=\"wpforms-904-field_64-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"64\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"904\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-904-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_9\">Are you the Patient? If no, please tell us<\/label><input type=\"text\" id=\"wpforms-904-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-904-field_9-error\" ><\/div><div id=\"wpforms-904-field_28-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_28\">Where and when did you have your latest MRI scan? (Required) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-904-field_28\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-904-field_28-error\" required><\/textarea><\/div><div id=\"wpforms-904-field_29-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"29\"><fieldset><legend class=\"wpforms-field-label\">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)<\/legend><ul id=\"wpforms-904-field_29\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_29_1\" name=\"wpforms[fields][29][]\" value=\"Yes\" aria-errormessage=\"wpforms-904-field_29_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_29_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_29_2\" name=\"wpforms[fields][29][]\" value=\"No\" aria-errormessage=\"wpforms-904-field_29_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_29_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-904-field_12-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"12\"><fieldset><legend class=\"wpforms-field-label\">Areas of Difficulty<\/legend><ul id=\"wpforms-904-field_12\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_12_1\" name=\"wpforms[fields][12][]\" value=\"Low Back\" aria-errormessage=\"wpforms-904-field_12_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_12_1\">Low Back<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_12_2\" name=\"wpforms[fields][12][]\" value=\"Mid Back\" aria-errormessage=\"wpforms-904-field_12_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_12_2\">Mid Back<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_12_3\" name=\"wpforms[fields][12][]\" value=\"Knee\" aria-errormessage=\"wpforms-904-field_12_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_12_3\">Knee<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_12_4\" name=\"wpforms[fields][12][]\" value=\"Other\" aria-errormessage=\"wpforms-904-field_12_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_12_4\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-904-field_13-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"13\"><fieldset><legend class=\"wpforms-field-label\">Has patient had spine surgery?<\/legend><ul id=\"wpforms-904-field_13\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_13_1\" name=\"wpforms[fields][13][]\" value=\"Yes\" aria-errormessage=\"wpforms-904-field_13_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_13_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_13_2\" name=\"wpforms[fields][13][]\" value=\"No\" aria-errormessage=\"wpforms-904-field_13_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_13_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-904-field_14-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_14\">What was done? When was it? Who was the surgeon?<\/label><textarea id=\"wpforms-904-field_14\" class=\"wpforms-field-small\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-904-field_14-error\" ><\/textarea><\/div><div id=\"wpforms-904-field_15-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"15\"><fieldset><legend class=\"wpforms-field-label\">Do you have Back Pain?<\/legend><ul id=\"wpforms-904-field_15\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_15_1\" name=\"wpforms[fields][15][]\" value=\"Yes\" aria-errormessage=\"wpforms-904-field_15_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_15_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_15_2\" name=\"wpforms[fields][15][]\" value=\"No\" aria-errormessage=\"wpforms-904-field_15_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_15_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-904-field_16-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Do you have Leg Pain? <\/legend><ul id=\"wpforms-904-field_16\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_16_1\" name=\"wpforms[fields][16][]\" value=\"Yes Right Leg\" aria-errormessage=\"wpforms-904-field_16_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_16_1\">Yes Right Leg<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_16_5\" name=\"wpforms[fields][16][]\" value=\"Yes Left Leg\" aria-errormessage=\"wpforms-904-field_16_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_16_5\">Yes Left Leg<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_16_4\" name=\"wpforms[fields][16][]\" value=\"Yes Both Legs (Equal Pain)\" aria-errormessage=\"wpforms-904-field_16_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_16_4\">Yes Both Legs (Equal Pain)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_16_6\" name=\"wpforms[fields][16][]\" value=\"Yes Both Legs (Not Equal Pain)\" aria-errormessage=\"wpforms-904-field_16_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_16_6\">Yes Both Legs (Not Equal Pain)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_16_2\" name=\"wpforms[fields][16][]\" value=\"No\" aria-errormessage=\"wpforms-904-field_16_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_16_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-904-field_17-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\">Leg Numbness<\/legend><ul id=\"wpforms-904-field_17\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_17_1\" name=\"wpforms[fields][17][]\" value=\"Yes Right Leg\" aria-errormessage=\"wpforms-904-field_17_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_17_1\">Yes Right Leg<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_17_4\" name=\"wpforms[fields][17][]\" value=\"Yes Left Leg\" aria-errormessage=\"wpforms-904-field_17_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_17_4\">Yes Left Leg<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_17_3\" name=\"wpforms[fields][17][]\" value=\"Yes Both Legs  (Equal Numbness)\" aria-errormessage=\"wpforms-904-field_17_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_17_3\">Yes Both Legs  (Equal Numbness)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_17_5\" name=\"wpforms[fields][17][]\" value=\"Yes Both Legs  (Not Equal Numbness)\" aria-errormessage=\"wpforms-904-field_17_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_17_5\">Yes Both Legs  (Not Equal Numbness)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_17_2\" name=\"wpforms[fields][17][]\" value=\"No\" aria-errormessage=\"wpforms-904-field_17_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_17_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-904-field_18-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"18\"><fieldset><legend class=\"wpforms-field-label\"> Leg Weakness<\/legend><ul id=\"wpforms-904-field_18\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_18_1\" name=\"wpforms[fields][18][]\" value=\"Yes Right Leg\" aria-errormessage=\"wpforms-904-field_18_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_18_1\">Yes Right Leg<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_18_4\" name=\"wpforms[fields][18][]\" value=\"Yes Left Leg\" aria-errormessage=\"wpforms-904-field_18_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_18_4\">Yes Left Leg<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_18_3\" name=\"wpforms[fields][18][]\" value=\"Yes Both Legs (Equal Weakness)\" aria-errormessage=\"wpforms-904-field_18_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_18_3\">Yes Both Legs (Equal Weakness)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_18_5\" name=\"wpforms[fields][18][]\" value=\"Yes Both Legs (Not Equal Weakness)\" aria-errormessage=\"wpforms-904-field_18_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_18_5\">Yes Both Legs (Not Equal Weakness)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_18_2\" name=\"wpforms[fields][18][]\" value=\"No\" aria-errormessage=\"wpforms-904-field_18_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_18_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-904-field_41-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"41\"><fieldset><legend class=\"wpforms-field-label\">Which Leg is worse overall?<\/legend><ul id=\"wpforms-904-field_41\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_41_1\" name=\"wpforms[fields][41][]\" value=\"Right\" aria-errormessage=\"wpforms-904-field_41_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_41_1\">Right<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_41_4\" name=\"wpforms[fields][41][]\" value=\"Left\" aria-errormessage=\"wpforms-904-field_41_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_41_4\">Left<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_41_3\" name=\"wpforms[fields][41][]\" value=\"Can not tell\" aria-errormessage=\"wpforms-904-field_41_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_41_3\">Can not tell<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-904-field_48-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"48\"><fieldset><legend class=\"wpforms-field-label\">Any bowel, bladder or sexual difficulty? (REQUIRED) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-904-field_48\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_48_1\" name=\"wpforms[fields][48][]\" value=\"Yes\" aria-errormessage=\"wpforms-904-field_48_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_48_1\">Yes<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_48_4\" name=\"wpforms[fields][48][]\" value=\"No\" aria-errormessage=\"wpforms-904-field_48_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_48_4\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-904-field_49-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_49\"> If Yes, please describe below.<\/label><textarea id=\"wpforms-904-field_49\" class=\"wpforms-field-small\" name=\"wpforms[fields][49]\" aria-errormessage=\"wpforms-904-field_49-error\" ><\/textarea><\/div><div id=\"wpforms-904-field_50-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"50\"><fieldset><legend class=\"wpforms-field-label\">Do you need any assistance to walk (cane, crutch, wheelchair)? (REQUIRED) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-904-field_50\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_50_1\" name=\"wpforms[fields][50][]\" value=\"Yes\" aria-errormessage=\"wpforms-904-field_50_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_50_1\">Yes<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_50_4\" name=\"wpforms[fields][50][]\" value=\"No\" aria-errormessage=\"wpforms-904-field_50_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_50_4\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-904-field_51-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_51\"> If Yes, please describe below.<\/label><textarea id=\"wpforms-904-field_51\" class=\"wpforms-field-small\" name=\"wpforms[fields][51]\" aria-errormessage=\"wpforms-904-field_51-error\" ><\/textarea><\/div><div id=\"wpforms-904-field_60-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"60\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"904\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3 last \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-904-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_20\">Patient&#039;s Date of Birth (MM\/DD\/YYYY)<\/label><input type=\"text\" id=\"wpforms-904-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" aria-errormessage=\"wpforms-904-field_20-error\" ><\/div><div id=\"wpforms-904-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_21\"> Patient&#039;s Sex<\/label><input type=\"text\" id=\"wpforms-904-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-904-field_21-error\" ><\/div><div id=\"wpforms-904-field_42-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_42\">Height<\/label><input type=\"text\" id=\"wpforms-904-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" aria-errormessage=\"wpforms-904-field_42-error\" ><\/div><div id=\"wpforms-904-field_43-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_43\">Weight<\/label><input type=\"text\" id=\"wpforms-904-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\" aria-errormessage=\"wpforms-904-field_43-error\" ><\/div><div id=\"wpforms-904-field_22-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_22\">Please tell us your exact symptoms: (back pain? leg pain? weakness? numbness? exactly where)<\/label><textarea id=\"wpforms-904-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-904-field_22-error\" ><\/textarea><\/div><div id=\"wpforms-904-field_23-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_23\">Describe patient&#039;s problem<\/label><textarea id=\"wpforms-904-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-904-field_23-error\" ><\/textarea><\/div><div id=\"wpforms-904-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_24\">The problem started when?<\/label><input type=\"text\" id=\"wpforms-904-field_24\" class=\"wpforms-field-medium\" name=\"wpforms[fields][24]\" aria-errormessage=\"wpforms-904-field_24-error\" ><\/div><div id=\"wpforms-904-field_25-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"25\"><fieldset><legend class=\"wpforms-field-label\">Have you had chiropractic treatments?<\/legend><ul id=\"wpforms-904-field_25\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_25_1\" name=\"wpforms[fields][25][]\" value=\"Yes\" aria-errormessage=\"wpforms-904-field_25_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_25_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_25_2\" name=\"wpforms[fields][25][]\" value=\"No\" aria-errormessage=\"wpforms-904-field_25_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_25_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-904-field_26-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_26\">Has patient seen a surgeon for a present problem? What was recommended?<\/label><textarea id=\"wpforms-904-field_26\" class=\"wpforms-field-small\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-904-field_26-error\" ><\/textarea><\/div><div id=\"wpforms-904-field_27-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_27\">What tests and treatment has patient had?<\/label><textarea id=\"wpforms-904-field_27\" class=\"wpforms-field-small\" name=\"wpforms[fields][27]\" aria-errormessage=\"wpforms-904-field_27-error\" ><\/textarea><\/div><div id=\"wpforms-904-field_30-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_30\">Describe your recent sport activities before your spine problem:<\/label><textarea id=\"wpforms-904-field_30\" class=\"wpforms-field-small\" name=\"wpforms[fields][30]\" aria-errormessage=\"wpforms-904-field_30-error\" ><\/textarea><\/div><div id=\"wpforms-904-field_31-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_31\"> Are you able to do any sport activity now? Describe:<\/label><textarea id=\"wpforms-904-field_31\" class=\"wpforms-field-small\" name=\"wpforms[fields][31]\" aria-errormessage=\"wpforms-904-field_31-error\" ><\/textarea><\/div><div id=\"wpforms-904-field_32-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"32\"><fieldset><legend class=\"wpforms-field-label\"> Do you or did you stress your back in your work?<\/legend><ul id=\"wpforms-904-field_32\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_32_1\" name=\"wpforms[fields][32][]\" value=\"Yes\" aria-errormessage=\"wpforms-904-field_32_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_32_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_32_2\" name=\"wpforms[fields][32][]\" value=\"No\" aria-errormessage=\"wpforms-904-field_32_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_32_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-904-field_33-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_33\">Describe your work?<\/label><textarea id=\"wpforms-904-field_33\" class=\"wpforms-field-small\" name=\"wpforms[fields][33]\" aria-errormessage=\"wpforms-904-field_33-error\" ><\/textarea><\/div><div id=\"wpforms-904-field_34-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_34\">Job Title now (or when you were working)<\/label><input type=\"text\" id=\"wpforms-904-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\" aria-errormessage=\"wpforms-904-field_34-error\" ><\/div><div id=\"wpforms-904-field_35-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_35\">Where did you hear about us<\/label><select id=\"wpforms-904-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\"><option value=\"Select One\" >Select One<\/option><option value=\"Vancouver Sun\" >Vancouver Sun<\/option><option value=\"Google_Search\" >Google_Search<\/option><option value=\"NY_Times\" >NY_Times<\/option><option value=\"Bing_Search\" >Bing_Search<\/option><option value=\"Twitter, now X\" >Twitter, now X<\/option><option value=\"Patient_Referral\" >Patient_Referral<\/option><option value=\"Youtube\" >Youtube<\/option><option value=\"Yahoo_Search\" >Yahoo_Search<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-904-field_59-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_59\">Are you taking any medication for weight loss or diabetes? Please list:<\/label><textarea id=\"wpforms-904-field_59\" class=\"wpforms-field-small\" name=\"wpforms[fields][59]\" aria-errormessage=\"wpforms-904-field_59-error\" ><\/textarea><\/div><div id=\"wpforms-904-field_46-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_46\">What medication are you taking and how often?<\/label><textarea id=\"wpforms-904-field_46\" class=\"wpforms-field-small\" name=\"wpforms[fields][46]\" aria-errormessage=\"wpforms-904-field_46-error\" ><\/textarea><\/div><div id=\"wpforms-904-field_57-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_57\">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<\/label><textarea id=\"wpforms-904-field_57\" class=\"wpforms-field-medium\" name=\"wpforms[fields][57]\" aria-errormessage=\"wpforms-904-field_57-error\" ><\/textarea><\/div><div id=\"wpforms-904-field_37-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_37\">If you have a google account, enter your google email address<\/label><input type=\"text\" id=\"wpforms-904-field_37\" class=\"wpforms-field-medium\" name=\"wpforms[fields][37]\" aria-errormessage=\"wpforms-904-field_37-error\" ><\/div><div id=\"wpforms-904-field_38-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_38\">Insurance Company Name<\/label><input type=\"text\" id=\"wpforms-904-field_38\" class=\"wpforms-field-medium\" name=\"wpforms[fields][38]\" aria-errormessage=\"wpforms-904-field_38-error\" ><\/div><div id=\"wpforms-904-field_39-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_39\">Insurance Type<\/label><select id=\"wpforms-904-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\"><option value=\"Select One\" >Select One<\/option><option value=\"PPO\" >PPO<\/option><option value=\"POS\" >POS<\/option><option value=\"HMO\" >HMO<\/option><option value=\"Medicare\" >Medicare<\/option><option value=\"Auto Insurance\" >Auto Insurance<\/option><option value=\"Affordable Cared Act\" >Affordable Cared Act<\/option><option value=\"Other\" >Other<\/option><option value=\"No Insurance\" >No Insurance<\/option><\/select><\/div><div id=\"wpforms-904-field_45-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"45\"><fieldset><legend class=\"wpforms-field-label\">CONSENT (REQUIRED)  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-904-field_45\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-904-field_45_1\" name=\"wpforms[fields][45][]\" value=\"By submitting this form, I give consent for the Back Institute to share my medical records with outside experts to get additional opinion and for them to contact me, understanding that &quot;NANO&quot; endoscopic is not available elsewhere.\" aria-errormessage=\"wpforms-904-field_45_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-904-field_45_1\">By submitting this form, I give consent for the Back Institute to share my medical records with outside experts to get additional opinion and for them to contact me, understanding that \"NANO\" endoscopic is not available elsewhere.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-904-field_63-container\" class=\"wpforms-field wpforms-field-captcha\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-904-field_63\">Custom Captcha <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label>\t\t\t<div class=\"wpforms-captcha-math\">\n\t\t\t\t<span id=\"wpforms-904-field_63-question\" class=\"wpforms-captcha-equation\">\n\t\t\t\t\t<span class=\"n1\">10<\/span>\n\t\t\t\t\t\t\t<span class=\"cal\">*<\/span>\n\t\t\t\t\t\t\t<span class=\"n2\">6<\/span>\t\t\t\t\t<span class=\"e\">=<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<input type=\"text\" id=\"wpforms-904-field_63\" class=\"wpforms-field-medium wpforms-field-required a\" data-rule-wpf-captcha=\"math\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][63][a]\" aria-errormessage=\"wpforms-904-field_63-error\" aria-describedby=\"wpforms-904-field_63-question\" required>\t\t\t\t<input type=\"hidden\" name=\"wpforms[fields][63][cal]\" class=\"cal\">\n\t\t\t\t<input type=\"hidden\" name=\"wpforms[fields][63][n2]\" class=\"n2\">\n\t\t\t\t<input type=\"hidden\" name=\"wpforms[fields][63][n1]\" class=\"n1\">\n\t\t\t<\/div>\n\t\t\t<\/div><div id=\"wpforms-904-field_62-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"62\"><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"904\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/pages\/120\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-904\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/backinstituteneurosurgery.com\/main\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n","protected":false},"excerpt":{"rendered":"<p>Initial Inquiry Form This is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you. Please fill out this questionnaire Currently, our practice is not participating in any clinical trials. We have noticed that our advertisement may have appeared in search results for trials, which was unintended.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"full-width.php","meta":{"footnotes":""},"class_list":["post-120","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/pages\/120","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/comments?post=120"}],"version-history":[{"count":13,"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/pages\/120\/revisions"}],"predecessor-version":[{"id":2049,"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/pages\/120\/revisions\/2049"}],"wp:attachment":[{"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/media?parent=120"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}