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Spinal Decompression Candidate Questionnaire
Please complete this form.
Birth Date (mm/dd/yyyy)
Are You Experiencing any of the following?
Chronic Neck Pain
Radiating Arm Pain
Numbness and/or tingling in arm, hand or fingers
Disc bulge or herniation in cervical spine (neck)
Spinal stenosis in cervical spine (neck)
Arthritis in cervical spine (neck)
Chronic Lower Back Pain
Radiating Leg Pain
Spinal stenosis in lumbar support (lower back)
Disc bulge or herniation in lumbar support (lower back)
Arthritis in lumbar spine (lower back)
Radiating leg pain / sciatica" "Numbness and / or tingling in legs, heel or foot
Have you had lower back or neck surgery before?
Which of your activities of daily living are affected the most?
Playing with Children
What Result do you want most for yourself?
Restore quality of life
Restore optimum health
What types of treatment have you already tried?
When was your most recent MRI/Xray? (mm/dd/yyyy)
Rate your pain level today? (1 - 5)
How many years have you been suffering with this pain?
How important is your quality of life? (1 - 5)
If you would like to be contacted by Community Chiropractic Centre to book a no-charge consultation with Dr. Sarah Dale or Dr. Todd Small please indicate what time of day would be the best time to call and what phone number you would like to be contacted at?
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