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Contact Information

Name* Email*
Address City*
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Phone Number Best time for us to call you

Medical Information

Are you the Patient? If no, please tell us
YesNo If no,
Areas of Difficulty
Has patient had spine surgery? YesNo
What was done? When was it?
Who was the surgeon?
Do you have Back painRight Leg PainLeft Leg PainLeg NumbnessLeg WeaknessNeck PainRight Arm PainLeft Arm PainArm NumbnessArm Weakness
Patient's Age
Patient's Sex MaleFemale
Please tell us your exact symptoms:
(back pain? leg pain? weakness? numbness? exactly where)
Describe patient's problem
The problem started when?
Have you had chiropractic treatments? YesNo
Has patient seen a surgeon for a present problem? What was recommended?
What tests and treatment has patient had?
Where and when did you have your latest MRI scan?
Are you going to have your MRI scan report faxed to our national receiving fax at 310-659-8869?
(Attn: Dr. David Ditsworth, Chief of Neurosurgery)
Describe your usual sport activities before your spine problem?
Are you able to do any sport activity now? Describe:
Do you stress your back in your work? YesNo
Describe your work?
Job Title?
What would you like to ask us?
Where did you hear about us If Other

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