Medical Information

Are you the Patient? If no, please tell us

Areas of Difficulty

Select One Neck Mid Back Low Back Knee Other

Has patient had spine surgery?

Yes No

What was done? When was it? Who was the surgeon?

Do you have

Back Pain? Yes No    Leg Numbness? Yes No Neck Pain? Yes No    Leg Weakness? Yes No

Patient's Age

Patient's Sex

Patient's Job

Please tell us your exact symptoms:(back pain? leg pain? weakness? numbness? exactly where)

Describe patient's problem
The problem started when?
Has patient had a scan? What did it show?

Has patient seen a surgeon for the present problem? What was recommended?
What tests and treatment has patient had?
What would you like to ask us?
Where did you hear about us?	SelectOne AOL_Search Bing_Search Facebook_search Google_search Newspaper_Times Patient_Referral TV_Commercial WebMD_search Yahoo_Search    If Others,

• You can submit your question now Or

• You can fill out more detailed information about you, This will allow us to provide you with more accurate information

More Detailed Information

Insurance Company Name

Type

Select One PPO POS HMO Workers Comp Auto Insurance Other