Name: Intouch Chiropractic
Price range: $

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 seeing 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

Spinal Decompression Survey

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) 313-5403.

Change Your Quality of Life Today

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) 313-5403.

Change Your Quality of Life Today

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