Step 1: Tell Us About Your ConditionWhat condition do you have? Bulging Disc Degenerative Disc Disease Disc Tear Facet Joint Disease Failed Fusion Surgery Failed Surgery Syndrome Foraminal Stenosis Herniated Disc Pinched Nerve Radiculitis Radiculopathy Sciatica Spinal Bone Spurs Spinal Stenosis Spondylolisthesis Other Other condition:How long have you been experiencing pain? 1 Month or less 1 - 6 Months 7 - 12 Months 1 Year or more Have you undergone any of the following studies? CT Scan MRI Myelogram X-Ray Nerve Conduction Study Viscogram Other None How long ago was your last study done? 1 Month or less 1 - 6 Months 7 - 12 Months 1 Year or more Step 2: Tell Us About Your TreatmentAre you currently undergoing any treatment? Medication Chiropractic Care Massage Acupuncture Epidurals Physical Therapy Nerve Block Injections Cortisone Injections Other None If other treatment, please explain:How effective is your current treatment? Not Very Somewhat Very How long does the treatment help with your pain? 1 - 7 Days 2 - 4 Weeks 2 - 3 Months 3 - 6 Months 6 - 12 Months More Than One Year Have you been recommended for a specific treatment you have not yet undergone? EMG Viscogram Medication Chiropractor Acupuncture Physical Therapy Nerve Study Nerve Block Injections Cortisone Injections Other None If other, please explain:Step 3: Tell Us About YourselfFirst Name*Last Name*Email*Phone*Insurance*Select your insurance typeAARPAetnaBeech StreetBlue Cross / Blue ShieldCaterpillarCignaCoventryHarvard PilgrimHumanaLiberty MutualUnited HealthcareMedicareOtherSelf PayOther Insurance*CommentsNameThis field is for validation purposes and should be left unchanged.
