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Here's your chance for a mini-consultation with one of our Specialist. If you fill out this form and submit it, we will contact you by mail or email with information pertinent to your online questionnaire. Please be as truthful and accurate as possible.
 
Items marked with * are required
* What is your sex? Male Female
* What is Age Range?
* Where does it hurt (check all the areas that are painful)
Head or Face Wrist, Hand or Forearm
Neck Abdomen
Shoulders Front of Pelvis
Middle Back Hips or Thighs
Lower Back Knees
Chest Shins
Arm or Elbow Ankle or Feet
* Describe the most painful area (use a 0-10 pain scale....0 being not painful 10 being excruciating)
* When did it start, and what makes it better and worse?
If there's a second area of complaint, describe it here (use 0-10 pain scale)
The reason for treatment is due to a:
Work Related Injury
Automobile Accident
Athletic Injury
Progressive-No one injury
Unknown
Describe any condition that may be related to your pain such as your general health
Describe Treatments You Have Received and Medications That You Are Taking
* Do you have any of the following (if you don't know what it is, do not check the box):
Aortic Aneurysm
Spondylolisthesis
Moderate to Severe Osteoporosis
Pregnancy
Lumbar Spinal Fusion or Metal Hardware
Spinal or Pelvic Cancer
A Recent Low Back Fracture
Connective tissue disease such as Lupus, Rheumatoid Arthritis or Scleroderma
I Don't Believe I have Any of These Conditions

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Contact Information
Be sure to click "SUBMIT FORM" to send all your information.
We will respond to you within 72 hours. If you need immediate attention,
please call 972-781-0010 and we will do our best to see you the same day.