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- - - All Conditions
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Mod Spine
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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?
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?
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?
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?
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?
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?
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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The Advanced Spine Center embraces a multidisciplinary approach & the latest innovations in minimally invasive spine care to deliver an individualized recovery experience to our patients.

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COVID-19 UPDATE: During this time, our regular office hours may be adjusted. However, your health still comes first. We will be offering ONLINE appointments and consultation options to enhance access to our services. Call today to learn more!