Skip to content
Home
About
Spinal Decompression
About spinal decompression
Spinal Decompression FAQs
Laser therapy
Conditions
Auto injury
Bulging disc
Degenerative disc disease
Laser therapy
Lower back and leg pain
Microdiscectomy
Neck and Arm Pain
Sciatica
Spinal Adjustments And Manipulation
Therapeutic Exercise
Patient Resources
Blog
Financing
Testimonals and Reviews
Clinical studies and useful links
Spinal Wellness Tips
Videos
New Patients
Evaluation form
What To Expect?
Do I Need an MRI?
About Chiropractic
Q&A
Contact
Menu
Home
About
Spinal Decompression
About spinal decompression
Spinal Decompression FAQs
Laser therapy
Conditions
Auto injury
Bulging disc
Degenerative disc disease
Laser therapy
Lower back and leg pain
Microdiscectomy
Neck and Arm Pain
Sciatica
Spinal Adjustments And Manipulation
Therapeutic Exercise
Patient Resources
Blog
Financing
Testimonals and Reviews
Clinical studies and useful links
Spinal Wellness Tips
Videos
New Patients
Evaluation form
What To Expect?
Do I Need an MRI?
About Chiropractic
Q&A
Contact
253-553-3472
New patient evaluation form
Fill out this quick form and someone will follow up with you shortly.
1
2
3
Tell us about your pain.
1. What is your current level of pain?
(Required)
1
2
3
4
5
6
7
8
9
10
If your pain comes and goes then choose how severe the pain is on a typical pain episode.
2. What is your source of pain? (check all that apply)
(Required)
Lower Back
Herniated Disc
Mid Back
Bulging Disc
Sciatic leg pain
Tingling in Toes or Feet
Degenerative disc disease
Neck and arm pain
Auto Accident Injuries
3. What type of doctors have you seen for your pain? (check all that apply)
(Required)
Chiropractor
Pain Management
Orthopedic Surgeon
Neurologist
General Doctor
Other
None
4. When did your pain begin?
(Required)
Less than a month ago
1-3 months ago
3 to 12 months ago
More than a year ago
5. What medications or treatments are you receiving for your pain? (check all that apply)
(Required)
Chiropractic Treatment
Physical Therapy
Accupuncture
Opioid Pain Medication
Muscle Relaxants
NSAID
Other / Unsure
None
How Did it Happen?
1. How did the pain begin? (check all that apply)
(Required)
Accident at Home
Vehicle Accident
Accident at Work
Just Began
After Surgery
Came on Gradually
After an Illness
Sports Related
Other
2. Check any of the following tests you have had for this condition. (check all that apply)
(Required)
MRI
CAT Scan
X-Ray
EMG
Other Test
None
3. Have you had any of the following treatments / procedures? (check all that apply)
(Required)
Joint Injection
Trigger Point Injections
Nerve Block
Percutaneous Discectomy
None of the above
4. Have you had any surgeries related to your existing pain?
(Required)
Yes
No
How serious do you view your condition?
(Required)
Do you have any additional information about your condition you want us to know or any questions about treatment options we can help answer?
Name
(Required)
First
Last
Email (used to send treatment qualification information)
(Required)
Phone Number
(Required)
What is the best time to contact you?
(Required)
Hours
:
Minutes
AM
PM
AM/PM
CAPTCHA
