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Dedicated to Neck & Back Pain Management.
 

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*Name : *Age :
*E-mail : Phone:
Mobile : *Address :
*City : *State :
Country :
       
Symptoms / Pain Description
Check all symptoms that apply:
Weakness
Trouble Sitting
Trouble Standing
Trouble Walking
Has your condition been diagnosed by a professional?
Yes No
Have you been told by a physician that you may need spine surgery?
Yes  No
Briefly describe your symptoms, indicating when and how they began, and if your conditon has been treated by a physician in the past.
Diagnostic Tests
Have you seen any of the following Doctors?
Please indicate if any of the following doctors have recommended surgery.
Neurosurgeon
Name: Diagnose:
Date:
Primary Care Physician
Name: Diagnose:
Date:
Pain Management Specialist
Name: Diagnose:
Date:
Spine Surgeon
Name: Diagnose:
Date:
Neurologist
Name: Diagnose:
Date:
Orthopedist
Name: Diagnose:
Date:
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