Check any or all of the modifiers that most closely describe your pain:*

Dull
Throbbing
Pins & Needles
Chronic Pain
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Which best describes the frequency of your pain?*

Intermittent (0-25% of day)
Often (more than 25% of day)
Chronic (most of the day)
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Have you already contacted a doctor about your pain?*

Yes
No
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Have you had back surgery?*

Yes
No
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Are you scheduled for back surgery?*

Yes
No
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Have you been diagnosed with any of the following?*

Disc Herniation
Sciatica
Bulged Disc
Disc Degeneration
Other
Have not been diagnosed
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Which more closely describes your pain level by time of day:*

AM
PM
All the time
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If there is a way to relieve your pain with an advanced non-surgical treatment program, are you interested in scheduling a consult with our doctor?*

Yes
No
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