Spine Surgery Screening Form

Fields in RED Are Required!

Name:
Age:
Email Address:
Is this injury work related?	YesNo
Motor Vehicle Accident:	YesNo
Height ( Format x'xx"):
Weight:
Smoking Status:	YesNo
If yes, how many packs per day:
Chief Complaint:	Neck/Arm PainBack/Leg Pain
On a scale of 1-10 (10 is the worst pain imaginable), rate your pain of the following areas
Neck:	12345678910
Shoulder:	12345678910
OR
Back:	12345678910
Buttock/Leg:	12345678910
Would you ever rate your pain a zero:	YesNo
When does your pain begin:
Do you have numbness and/or tingling:	YesNo
If yes, where is it located:

Do you have weakness:	YesNo
If yes, where is it located:

Your symptoms are worse with:

Your symptoms get better with:

Have you ever had loss of bowel or bladder function:	YesNo
Have you previously had spine surgery:	YesNo
If yes, please describe procedure performed, date of surgery, surgeon, etc.:

Have you had an MRI within the last 6 months:	YesNo
If yes, what body part was MRI of:
Work Status:	Full DutyLight DutyOffOther
If Other, please specify:

Who has previously treated you for your back or neck pain:

Have you had physical therapy:	YesNo
If yes, how much:

Have you had chiropractic care:	YesNo
Have you had injections:	YesNo
If yes, how many:
Have you taken medication for this problem:	YesNo
Have you tried other treatments for this problem:	YesNo