Decompression Survey – Chiropractor Las Vegas, NV

This Survey Could Change Your Quality of Life

Please check any or all of the primary pain complaints you are experiencing

Neck
Low Back
Buttocks
Hip
Leg
Calf
Foot
Toes

How long have you had the pain?

Less than a month
More than 6 weeks
More than 6 months
More than 1 year

Which best describes the frequency of your pain?

Intermittent (0-25% of day)
Occasional (26-50% of day)
Frequent (51-75% of day)
Constant (76-100% of day)

Have you already contacted a doctor about your pain?

Yes
No

Have you had back surgery?

Yes
No

Are you scheduled for back surgery?

Yes
No

Have you been diagnosed with any of the following

Disc Herniation
Disc Bulge
Sciatica
Spinal Stenosis
Disc Degeneration
Spondylolisthesis

My condition and pain has affected my activities as follows

Pain Sitting
Pain Standing
Trouble Walking
Interrupted Sleep at NIGHT
Decreased Activities
Decreased Pace

When is your pain at its worst? Describe how you feel and are affected

When was the last time you felt really great?

If there is a way to relieve your pain with one of our advanced non-surgical treatment programs, are you interested in scheduling a consult with our doctor?

Yes
No

What is the best time to contact you?

Morning
Afternoon
Evening

Full Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

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