New Patient Evaluation Form

Step 1 of 5

Tell us about your pain.

What is your current level of pain?

1-3
4-6
7-9
10 (Extreme Pain)
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What is your source of pain? (check all the apply)

Lower Back

Herniated Disc

Bulging Disc

Leg Pain

Tingling Toes Or Feet

Neck

Other

When did your pain begin?

Less than month ago.

1-3 months ago.

3-12 months ago.

More than a year ago.

Step 2 of 5

What type of doctors have you seen for your pain? (check all the apply)

Chiropractor

Pain Management

Orthopedic Surgeon

Neurologist

General Doctor

None

What medications or treatments are you receiving for your pain? (check all that apply)

Chiropractic Adjustments

Acupuncture

Opioid Pain Medication

Muscle Relaxants

Physical Therapy

NSAID

Other

How did the pain begin?

Vehicle Accident

Work Accident

Happened Randomly

After Surgery

Came on gradually.

After Illness

Sports

Other

Step 3 of 5

Have you had a test for your condition? Check all that apply.

X-Ray

MRI

CT Scan

Physical Examination Tests

Other

Have you had any surgeries for your pain?

Yes

No

How serious would you consider your back pain/ condition?

Do you have any additional information about your situation or any questions about treatment options we can help answer?

Step 4 of 5

First Name

Last Name

Phone *

Email *

Last Step!

Postal code *

What is your credit score? (Used for potential financing options) *

Poor Credit (Below 650)

Average Credit (650-700)

Good Credit (700-750)

Great Credit (750+)

Whats the best time to contact you? *

Mornings (Before Noon)

Afternoon (12PM-4PM)

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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