You can always press Enter⏎ to continue
Spine Health Assessment
Complete the assessment to determine if you're qualified to see a Baylor Medicine spine specialist.
6
Questions
START
HIPAA
Compliance
1
Unique ID
Previous
Next
Submit
Press
Enter
2
Where along your spine are you experiencing pain or is the issue located?
Select all that apply
Neck
Middle Back
Upper Back
Lower Back
Pelvis or Tailbone
Entire Spine
Previous
Next
Submit
Press
Enter
3
How long have you been experiencing spine pain or has your spine's health been a concern?
Days
Weeks
Months
Years
Previous
Next
Submit
Press
Enter
4
Have you seen a doctor or other medical provider about your spine issue(s)?
YES
NO
Previous
Next
Submit
Press
Enter
5
What kind of medical provider have you seen?
Select all that apply.
Chiropractor
Primary Care Doctor
Physical Therapist
Specialist
Surgeon
Other
Previous
Next
Submit
Press
Enter
6
Based on your answers, we know we can help you out. Would you like to request an appointment with the Baylor Medicine Spine Center?
YES
NO
Previous
Next
Submit
Press
Enter
7
Please provide your contact information and we will call you back!
For a list of accepted insurance/healthcare plans visit baylormedicine.org/insurance as well as the Spine Center For Patients page.
First and last name as it appears on your government issued ID
Email
Preferred phone number
Previous
Next
Submit
Press
Enter
Should be Empty:
Spine Assessment Form
[Edit]
Question Label
1
of
7
See All
Go Back
Submit
