Spinal Decompression Survey - Chiropractor San Diego CA

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Spinal Decompression SurveyDr. Devin Young2021-05-12T15:14:52-07:00

Take the First Step…

Are You a Candidate for NUCCA Spinal Care or
Non-Invasive, Non-Surgical Spinal Decompression?

Complete the Survey Below, or Call Us at (619) 756-7510.

Change Your Quality of Life Today
Please select areas of pain that you are experiencing
- Neck
- Low Back
- Buttocks
- Hip
- Leg
- Calf
- Foot
- Toes
How long have you had the pain?
- Less than a month
- More than 6 weeks
- More than 6 months
- More than 1 year
Which best describes the frequency of your pain?
- Intermittent (0-25% of day)
- Occasional (26-50% of day)
- Frequent (51-75% of day)
- Constant (76-100% of day)
Have you seen a doctor for your pain?
- Yes
- No
Have you had back surgery?
- Yes
- No
Are you scheduled for back surgery?
- Yes
- No
Have you been diagnosed with any of the following:
- Disc Herniation
- Disc Bulge
- Sciatica
- Spinal Stenosis
- Disc Degeneration
- Spondylolisthesis
My condition and pain affect the following activities:
- Pain Sitting
- Pain Standing
- Trouble Walking
- Interrupted Sleep at NIGHT
- Decreased Activities
- Decreased Pace
What time of day is your pain at its worst? Describe how the pain feels.
When was the last time you felt really great?
If there is a way to relieve your pain with one of our advanced non-surgical treatment programs, are you interested in scheduling a consult with our doctor?
- Yes
- No
What is the best time to contact you?
- Morning
- Afternoon
- Evening
Full Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
How Did You Hear About Our Office?*
- Referral
- NUCCA.org
- Google
- Facebook
- Other

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2425 Camino Del Rio South #100
San Diego, CA 92108
Chiropractor San Diego | Mission Valley

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