Symptom Quiz Patient Symptom Quiz "*" indicates required fields Step 1 of 4 25% Where are you experiencing the most pain, tenderness or tightness?* Neck or Upper Back Hands or Arms Middle Back Lower Back Hips or Tailbone Feet or Legs Are you experiencing any of the following symptoms? (Choose all that apply)* Neck pain Back pain Migraines Pain that worsens with inactivity Pain that worsens with walking, vigorous activity, or shifting positions Numbness or tingling in the extremities Muscular spasms or weakness Stiffness Visible signs of spinal deformity Other Please explain... How long have you been experiencing these symptoms?Choose an option belowLess than 2 weeks2 weeks to 1 month1 month to 6 months6 months to 1 year1 year or longerWhen is your pain at its worst? First thing in the morning While completing my daily activities or exercising Immediately before bedtime My pain wakes me up while I’m sleeping When does your pain feel better? First thing in the morning While walking or shifting positions When I’m at rest When bending forward While extending the spine I am in constant pain Do you know what originally caused your pain? Spinal injury (e.g. whiplash or improper lifting) Spinal deformity Muscular strain or sprain Prolonged inactivity (e.g. sitting at a desk) Degenerative disease (e.g. osteoarthritis or osteoporosis) Unknown Can you describe any other symptoms not listed above? Have you had any of the following medical exams or tests?* Blood sample CT scan or X-Ray Diagnostic injections MRI Nerve conduction study Range of motion or reflex test Physical examination Other Please explain... How recent were your medical exams or tests taken?Choose an option belowLess than 2 weeks2 weeks to 1 month1 month to 6 months6 months to 1 year1 year or longerCan you describe any other medical exams not listed above? Name* First Last Phone Number*Email* Would you like to receive additional information about our latest minimally invasive procedures?* Yes No Additional Comments or QuestionsCAPTCHA
