Utilize this form for a free preliminary review of your records. This free review does not constitute a medical evaluation by our physicians but can help us to determine whether or not we believe that we might be able to assist you. Please either fax this form along with your MRI report to 850-892-4212 or by mail: 101 MicroSpine Way, DeFuniak Springs, FL 32435.

 

 

 

Please fill in pain diagram below with the following:       Name:_______________________________ 

Pain                               xxxxxxxx                                           Phone: ______________________________

Aching                           - - - - - - - - -                                      Email: _______________________________

Burning                          111111111111                             Address:_____________________________

Pins and Needles            ooooooooooo                              City: _______________State_____Zip______

Numbness                     nnnnnnnnnnn                       Sex: M/F________DOB__________________

On a scale from 0 - 10, circle the level of your pain:  0     1     2     3     4     5     6     7     8     9     10

Circle the appropriate Information Below:

Where is your Worst pain? Neck / Arms / Headache / Torso / Mid Back / Low Back / Buttocks / Legs

Second worst pain (if applicable)? Neck / Arms / Headache / Torso / Mid Back / Low Back / Buttocks / Legs

Describe Your Pain: ____________________________________________________________________________ 

Have you had spine surgery previously? Y / N, and if yes, what was performed on you? ________________________

What treatments have you had for this condition? Pain management / P.T./ Chiropractor / Osteopathic

Briefly describe what was done by the above:___________________________________________________________

Any Significant Health Problems that might affect surgery? ________________________________________________