Take Your Free Online Pain Relief Survey

Drug Free Pain Relief !

Complete this mini-consultation, and one of our specialists will contact you by mail or email with information pertinent to your health concerns. Please be as truthful and accurate as possible.

Gender*

Male Female

Age Range*

0-10 11-20 21-30 31-40 41-50 51+

Where does it hurt?

Head or Face Neck Shoulders Middle Back Lower back Chest Arm or Elbow Wrist, Hand or Forearm Abdomen Front of Pelvics Hips or Thigh Knees Shins Ankle or Feet

Describe the most painful area*

(Use a 0-10 pain scale...0 being not painful, 10 being excruciating)

When did it start and what makes it better and worse*

If there's a second area of complaint, describe it here*

(Use a 0-10 pain scale)

The reason for treatment is due to a:*

Work related injury Automobile Accident Athletic Injury Progressive (no one injury) Unknown

Describe any condition that may be related to your pain*

(Such as your general health)

Describe treatments you have received and medications that you are taking

Do you have any of the following (If you don't know what it is, do not check the box)

Aortic Aneurysm Spondylolisthesis Moderate to Severe Osteoporosis Pregnancy Lumbar Spinal Fusion or Metal Hadware Spinal or Pelvic Cancer A Recent Low Back Fracture Connective tissue disease like Lupus, Rheumatoid, Arthritis or Scieroderma I DON'T BELIEVE I HAVE ANY OF THESE CONDITIONS

First Name*

Last Name*

Email*

Phone*

City*

State*

Zip/ Postal*

How did your hear about us?*

Privacy Policy
Terms & Conditions
Legal Disclaimer

Visit Us

3085 East Russell Road Suite E
Las Vegas, Nevada 89120

Call Today!

(702) 433-8333

Take Your Online Pain Relief Survey

Spine Wellness Center