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Spinal Decompression Survey
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Spinal Decompression Survey
Spinal Decompression Survey
Dr. Devin Young
2019-12-16T16:33:33-08:00
Complete This Survey to See if You Are a Candidate for
Non-Invasive, Non-Surgical Spinal Decompression
Please Complete the Questionnaire Below
to See if You Qualify by Phone, Call Us at (619) 313-5403
This Survey Could Change Your Quality of Life
Please check any or all of the primary pain complaints 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 already contacted a doctor about 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 has affected my activities as follows
Pain Sitting
Pain Standing
Trouble Walking
Interrupted Sleep at NIGHT
Decreased Activities
Decreased Pace
When is your pain at its worst? Describe how you feel and are affected
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
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