Are you a Candidate for a Minimally Invasive Procedure?

First Name*

Middle Name

Last Name*

Address*

City*

State*

Zip*

Date of Birth*

Phone*

Email*

Primary Insurance*

Preferred DISC Spine Location*

Where is your pain?* (Check ALL that apply)
NeckRight ArmLeft ArmBackRight LegLeft LegNo Pain

For neck and arm symptoms*

% neck

+

% arm

= 100%

% right arm

+

% left arm

= 100%

For back and leg symptoms*

% back

+

% leg

= 100%

% right leg

+

% left leg

= 100%

Where is your numbness and/or tingling?* (Check ALL that apply)
Right ArmLeft ArmRight LegLeft LegNo numbness or tingling

For how long have you been experiencing any type of pain/numbness/tingling?*

Over what period of time has it been seriously worsening?*

Do you have weakness of the arms?*

Do you have weakness of the legs?*

Calculate Your BMI Index

Height (feet)*

Height (inches)*

Weight (lbs)*

Your BMI Index

Have you tried anti-inflammatories?*

Have you tried PT?*

Have you tried steroid injections?*

Have you had x-rays of your neck or back in the past year?*

Have you had an MRI of your neck or back in the last year?*

Have you had a neck or back surgery before?*

If you had an MRI done within the last year, how do you plan to send us the CD and the report?*

MRI Review