1. Have you received a diagnosis from a physician for one of the following conditions: Herniated Disc, Ruptured Disc, Bulging Disc, Degenerative Disc, Sciatic Pain, Pinched Nerves, or Facet Syndrome?

Yes No

2. Have you received Chiropractic or Physical Therapy for your condition?

Yes No

3. Are you still experiencing Low Back Pain?

Yes No

4. Have you had Low Back Surgery?

Yes No

4a. If yes, What type of surgery?

Lamenectomy Discectomy Fusion

4b. If yes, Did your surgery involve implementation of hardware installation such as Rods or Screws?

Yes No

How Long have your experienced back pain?

0-30 Days 2-3 mos. 3-6 mos. 6-12 mos. 12+ mos.

6. Does you pain keep you from doing activities such as walking, sleeping, bending?

Yes No

7. Are you currently taking pain medication?

Yes No

8. If so, do you experience pain despite taking pain medication?

Yes No

9. Are you pregnant?

Yes No

10. Do you have any congenital defects of the spine?

Yes No

11. Do you have pelvis cancer?

Yes No

12. Have you been diagnosis with Severe Osteoporosis?

Yes No

13. What is your email?

Phone Number:

= Required