Candidacy Assessment Candidacy Check Tool Step 1 of 2 50% TELL US ABOUT YOU CONDITIONWhat condition do you have? Bulging Disc Degenerative Disc Disease Disc Tear Facet Joint Disease Failed Fusion Surgery Previous Surgery Foraminal Stenosis Herniated Disc Pinched Nerve Radiculitis Radiculopathy Sciatica Spinal Bone Spurs Spinal Stenosis Spondylolisthesis Other Other Condition Other conditionHow old are you?How old are you?21 - 3536 - 5051 - 6566+How would you rate your overall health?PoorFairGoodVery GoodExcellentDo you smoke cigarettes?NoOccassionallyRegularlyHave you already undergone non-surgical Medication Chiropractor Acupuncture Physical therapy Nerve block injections Cortisone injections None Other Other Treatments Other treatmentsHave you been recommended for surgery?YesNoIf yes, how long ago?A month or lessOne to six monthsSeven months to a yearMore than a year Name First Last Email PhoneDate of Birth MM slash DD slash YYYY InsuranceAARPAetnaBeech StreetBlue Cross / Blue ShieldCaterpillarCignaCoventryHarvard PilgrimHumanaLiberty MutualUnited HealthcareMedicareSelf PayOtherInsurance NumberInsurance Provider Phone NumberComments
