Spinal Decompression Form

Please fill out the application entirely and legibly. We need all information for insurance purposes.
Name
Social Security#
Date

MonthDayYear
Date of Birth

MonthDayYear
Age
MaleFemale
MarriedSingleDivorcedWidowed
# of children
MarriedSingleDivorcedWidowed
Address
City
State
Zip
Phone
Format: (000) 000-0000.
Email
example@example.com
Spouse's Name
Phone Number
Format: (000) 000-0000.
Your Occupation*
YesNo
Current or previous work
YesNo
YesNo
YesNo
YesNo
In Case of Emergency Contact
Phone Number
Format: (000) 000-0000.
TELL US ABOUTY YOUR PAST HEALTH:
Lower Back PainLeg or Foot Pain/NumbnessSpinal FracturesSpinal StenosisSpinal ArthritisSciaticaNeck PainHerniated DiscDiabetesHand ProblemsNeuropathyHeart AttackHeart ProblemsHigh/Low Blood PressureVascular Leg ProblemsVascular SurgeryStrokeHigh CholesterolShinglesKnee SurgeryKidney Issues or DialysisGoutHip SurgeryLeg FracturesJoint ReplacementFoot Surgery
PLEASE LIST ANY MEDICATIONS AND/OR VITAMINS YOU ARE CURRENTLY TAKING:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
PLEASELIST BELOW ANY SERIOUS MEDICAL CONDITIONS YOU HAVE HAD:
YesNo
NAME OF YOUR PRIMARY CARE PHYSICIAN
PLEASE LIST BELOW ANY BACK, KNEE, OR LEG SURGERIES YOU'VE HAD?
YesNo
YesNo
WHAT?
YesNo
AROUND WHAT TIME?
WHAT KIND OF PROBLEM(S) ARE YOU HAVING?
WHEN DID THIS BEGIN
WHAT MAKES IT BETTER
WHAT MAKES IT WORSE
Stabbing-SharpStingsElectric-ShocksAcheColdNumbnessTinglingTirednessSwellingCrampingBurning
SleepWalkingWorkStandingDaily RoutineShoppingChores
How would you describe your average pain over the past week (1-10)? (1 = no pain, 10=worst pain possible)
Please indicate what you consider to be an acceptable level of pain after completion of the treatment, if you have to accept some pain (1-10)?
It's getting better in its ownIt's staying the sameIt's getting worse as time goes by
List any daytime activities (you used to be able to do when you were feeling better) that are now limited
List the three main "health goals" that you would like to accomplish:
1.
2.
3.
A. I hereby authorize release of any medical information necessary to evaluate my case or process any future claims.

B. I authorize payment of any medical benefits from third parties for any future charges submitted to be paid directly to this office.

We invite you to discuss with us any questions regarding our services and or fees. The best health services are based on a friendly, mutual understanding between the provider and patient.

I understand the above information and guarantee this form was completed correctly to the best of my knowledge. I understand it is my responsibility to inform this office of any changes in my medical or insurance status.
Signature*

Clear
Date

MonthDayYear
Date
HOW DID YOUHEAR ABOUT OUR OFFICE?
WALKING SCALE QUESTIONNAIRE
These questions ask about limitations to your walking due to pain during the past 2 weeks. For each statement please circle the one number that best describes your degree of limitation. Please check you have circled one number for each question. Please hand this to the doctor at the start of your consultation

IN THE PAST2 WEEKS, HOW MUCH HAS YOUR PAIN

Rows	NOT AT ALL	A LITTLE	MODERATELY	QUITE A BIT	Extremely
LIMITED YOUR ABILITY TO WALK
LIMITED YOUR ABILITY TO RUN
LIMITED YOUR ABILITY TO CLIMB UP OR DOWN STAIRS?
MADE STANDING WHEN DOING THINGS MORE DIFFICULT?
LIMITTED YOUR BALANCE WHEN STANDING OR WALKING?
LIMITED HOW FAR YOU ARE ABLE TO WALK?
INCREASED THE EFFORT NEEDED FOR YOU TO WALK?
MADE IT NECESSARY FOR YOU TO USE SUPPORT WHEN WALKING INDOORS (E.G. HOLDING ON TO THE FURNITURE, USING A CATE, ETC.)?
MADE IT NECESSARY FOR YOU TO USE SUPPORT WHEN WALKING INDOORS (E.G. USING A CANE OR WALKER, ETC.)?
SLOWED DOWN YOUR WALKING?
AFFECTING HOW SMOOTHLY YOU WALK?
MADE YOU CONCENTRATE ON YOUR WALKING?

PROGRAM QUALIFICATION QUESTIONNAIRE (PLEASE ANSWER ALL THE FOLLOWING QUESTIONS BY CIRCLING ONE ANSWER PER QUESTION) THANK YOU FOR COMPLETING THIS QUESTIONNAIRE.
Right sideLeft sideBoth sides
YesNo
YesNoUnsure
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Should be Empty:

Current or previous work

PLEASE LIST ANY MEDICATIONS AND/OR VITAMINS YOU ARE CURRENTLY TAKING:

WALKING SCALE QUESTIONNAIRE