Patient Portal
Out-of-State &
International Patients
(973) 538-0900
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Patient Portal
Out-of-State &
International Patients
MENU
MENU
ABOUT US
Our Practice
Our Team
Dr. Charles Gatto
Dr. George Naseef
Dr. Jason Lowenstein
LOCATIONS
Our Locations
Bridgewater, NJ Office Location
Morristown, NJ Office Location
Rockaway, NJ Office Location
Sparta, NJ Office Location
PATIENT INFO
Patient Info & Forms
Patient Quizzes
Patient Pain Quiz
Patient Symptom Quiz
Patient Treatment Quiz
CONDITIONS
All Conditions
Ankylosing Spondylitis
Annular Tear
Back & Neck Pain
Bone Spurs
Bulging Disc
Degenerative Disc Disease
Facet Joint Pain
Failed Back Syndrome
Herniated Disc
Kyphosis
Osteoarthritis
Osteoporosis
Pediatric Spine
Pinched Nerve
Radiculopathy
Sacroiliac Joint Pain
Sciatica
Scoliosis
Spinal Deformities
Spinal Infections
Spinal Injuries
Spinal Stenosis
Spondylolisthesis
Spondylosis
TREATMENTS
All Treatments
Anterior Cervical Discectomy & Fusion (ACDF)
Anterior Lumbar Interbody Fusion (ALIF)
Anterior Scoliosis Correction
Artificial Disc Replacement
Endoscopic Discectomy
Facetectomy
Foraminotomy
Kyphoplasty
Laminectomy
Laser Spine Surgery
Microdiscectomy
Osteotomy
Posterior Cervical Laminoplasty
Posterior Lumbar Interbody Fusion (PLIF)
Revision Spine Surgery
Scoliosis Bracing
SI Joint Fusion
Spinal Cord Stimulator
Transforaminal Lumbar Interbody Fusion (TLIF)
Vertebral Body Tethering
MOD SPINE
CONTACT US
MENU
MENU
ABOUT US
Our Practice
Our Team
Dr. Charles Gatto
Dr. George Naseef
Dr. Jason Lowenstein
LOCATIONS
Our Locations
Bridgewater, NJ Office Location
Morristown, NJ Office Location
Rockaway, NJ Office Location
Sparta, NJ Office Location
PATIENT INFO
Patient Info & Forms
Patient Quizzes
Patient Pain Quiz
Patient Symptom Quiz
Patient Treatment Quiz
Out-of-State &
International Patients
CONDITIONS
All Conditions
Ankylosing Spondylitis
Annular Tear
Back & Neck Pain
Bone Spurs
Bulging Disc
Degenerative Disc Disease
Facet Joint Pain
Failed Back Syndrome
Herniated Disc
Kyphosis
Osteoarthritis
Osteoporosis
Pediatric Spine
Pinched Nerve
Radiculopathy
Sacroiliac Joint Pain
Sciatica
Scoliosis
Spinal Deformities
Spinal Infections
Spinal Injuries
Spinal Stenosis
Spondylolisthesis
Spondylosis
TREATMENTS
All Treatments
Anterior Cervical Discectomy & Fusion (ACDF)
Anterior Lumbar Interbody Fusion (ALIF)
Anterior Scoliosis Correction (ASC)
Artificial Disc Replacement
Endoscopic Discectomy
Facetectomy
Foraminotomy
Kyphoplasty
Laminectomy
Laser Spine Surgery
Microdiscectomy
Osteotomy
Posterior Cervical Laminoplasty
Posterior Lumbar Interbody Fusion (PLIF)
Revision Spine Surgery
Scoliosis Bracing
SI Joint Fusion
Spinal Cord Stimulator
Transforaminal Lumbar Interbody Fusion (TLIF)
Vertebral Body Tethering
MOD SPINE
CONTACT US
Patient Pain Quiz
Where are you experiencing the most pain?*
Where are you experiencing the most pain, tenderness or tightness?
*
Neck or Upper Back
Middle Back
Lower Back
Where are you experiencing the most pain, tenderness or tightness?*
Where are you experiencing the most pain, tenderness or tightness?
*
Neck or Upper Back
Hands or Arms
Middle Back
Lower Back
Hips or Tailbone
Feet or Legs
Have you been diagnosed with any of the following conditions?*
Do you have any of the following conditions? (Choose all that apply)*
*
Facet Joint Pain
Failed Back Syndrome
Herniated Disc
Sacroiliac Joint Pain
Sciatica
Spinal Deformity
Spinal Injury
Spinal Stenosis
Spondylolisthesis
Spondylosis
Not Sure
Facet Joint Pain
Failed Back Syndrome
Herniated Disc
Sacroiliac Joint Pain
Sciatica
Spinal Deformity
Spinal Injury
Spinal Stenosis
Spondylolisthesis
Spondylosis
Not Sure
Symptoms & Pain History
Are you experiencing any of the following symptoms? (Choose all that apply)
*
Neck pain
Back pain
Migraines
Pain that worsens with inactivity
Pain that worsens with walking, vigorous activity, or shifting positions
Numbness or tingling in the extremities
Muscular spasms or weakness
Stiffness
Visible signs of spinal deformity
Other
How long have you been experiencing these symptoms?
Choose an option below
Less than 2 weeks
2 weeks to 1 month
1 month to 6 months
6 months to 1 year
1 year or longer
When is your pain at its worst?
First thing in the morning
While completing my daily activities or exercising
Immediately before bedtime
My pain wakes me up while I’m sleeping
When does your pain feel better?
First thing in the morning
While walking or shifting positions
When I’m at rest
When bending forward
While extending the spine
I am in constant pain
Do you know what originally caused your pain?
Spinal injury (e.g. whiplash or improper lifting)
Spinal deformity
Muscular strain or sprain
Prolonged inactivity (e.g. sitting at a desk)
Degenerative disease (e.g. osteoarthritis or osteoporosis)
Unknown
Can you describe any other symptoms not listed above?
Patient & Treatment History
Are you currently undergoing any of the following treatments for your pain?
*
Alternative therapy
Back braces
Electrical nerve stimulation
Exercise
Injections
Pain medications
Spinal realignment
Other
How effective is your current treatment?
Choose an option below
My treatment plan provides effective relief, but I’m interested in trying something new
My treatment plan provides moderately effective relief, but my pain reappears in a few weeks
My treatment plan provides temporary relief, but my pain reappears in a few hours or days
My treatment plan does not provide me with any relief or makes my pain worse
I do not currently have a treatment plan to address my pain
Have you tried any of the following treatments?
Acupuncture
Anti-inflammatory medications
Chiropractic care
Epidural steroid injections
Massage/Ultrasound
Narcotic medications
Orthotics
Traction
TENS units
Trigger point injections
Other
How effective were your previous treatments?
Choose an option below
My previous treatment plan was effective, but my pain has worsened since or I’m interested in trying something new
My previous treatment plan was moderately effective, but my pain never fully disappeared
My previous treatment plan seemed to provide temporary relief, but my discomfort would return in a few days
My previous treatment plan did not affect my pain or aggravated my condition
I do not have a previous treatment plan
Which of the following age ranges best describes you?
I am a child age 10 or younger
I am a pediatric patient between the ages of 11 and 18
I am a young adult between the ages of 19 and 30
I am an adult between the ages of 31 and 50
I am an adult between the pages of 51 and 65
I am older than 65 years of age
Do you, or anyone in your immediate family, suffer from any heart conditions?
*
Yes
No
Other
Would you consider yourself healthy enough for surgery
*
Yes
No
Not Sure
Can you describe any other current or treatments not listed above?
Patient & Treatment History
Are you currently undergoing any of the following treatments for your pain?
Alternative therapy
Back braces
Electrical nerve stimulation
Exercise
Injections
Pain medications
Spinal realignment
Other
How effective is your current treatment?
Choose an option below
My treatment plan provides effective relief, but I’m interested in trying something new
My treatment plan provides moderately effective relief, but my pain reappears in a few weeks
My treatment plan provides temporary relief, but my pain reappears in a few hours or days
My treatment plan does not provide me with any relief or makes my pain worse
I do not currently have a treatment plan to address my pain
Have you tried any of the following treatments?
Acupuncture
Anti-inflammatory medications
Chiropractic care
Epidural steroid injections
Massage/Ultrasound
Narcotic medications
Orthotics
Traction
TENS units
Trigger point injections
Other
How effective were your previous treatments?
Choose an option below
My previous treatment plan was effective, but my pain has worsened since or I’m interested in trying something new
My previous treatment plan was moderately effective, but my pain never fully disappeared
My previous treatment plan seemed to provide temporary relief, but my discomfort would return in a few days
My previous treatment plan did not affect my pain or aggravated my condition
I do not have a previous treatment plan
Which of the following age ranges best describes you?
*
I am a child age 10 or younger
I am a pediatric patient between the ages of 11 and 18
I am a young adult between the ages of 19 and 30
I am an adult between the ages of 31 and 50
I am an adult between the ages of 51 and 65
I am older than 65 years of age
Do you, or anyone in your immediate family, suffer from any heart conditions?
*
Yes
No
Other
Would you consider yourself healthy enough for surgery
*
Yes
No
Not Sure
Can you describe any other current or treatments not listed above?
Previous Exams & Insurance Information
Have you had any of the following medical exams or tests?
*
Blood sample
CT scan or X-Ray
Diagnostic injections
MRI
Nerve conduction study
Range of motion or reflex test
Physical examination
Other
How recent were your medical exams or tests taken?
Choose an option below
Less than 2 weeks
2 weeks to 1 month
1 month to 6 months
6 months to 1 year
1 year or longer
What type of insurance coverage do you have?
*
Exclusive Provider Organization
Health Maintenance Organization
Medicaid
Medicare
Preferred Provider Organization
Self-pay
Worker’s Compensation
Unknown
*
We are currently not accepting Medicaid at this
time. We apologize for any inconvenience.
What is the name of your insurance provider?*
Can you describe any other medical exams not listed above?
Personal Contact Details
First Name
*
Last Name
*
Phone Number
*
Email
*
Would you like to receieve additional information about our latest minimally invasive procedures?*
*
Yes
No
Additional Comments or Questions
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