Registration form for Spinal Decompression

Primary Information (Fields marked with an asterisk must be filled in)

Health History

Are you pregnant? *	Yes No
Do you smoke? *	Yes No
Do you use narcotics or steroids? *	Yes No

Do you currently have or have you ever had any of the following conditions:
Surgical repair	Yes No
Cancer	Yes No
Acute fractures of the vertebral column	Yes No
Paralysis of any kind	Yes No
Fusion	Yes No
Laminectomy	Yes No
Aneurysm	Yes No

Where is your pain located?

Do you have any radicular leg pain?

What type of treatments have you received in the past (PT, Chiropractor)?

Do you have a current MRI? How long ago? If not you must have one before treatments can begin.

Do you have any loved ones or other support system you would like to join you for the Consultation? If so please list below.

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Frequently Asked Questions