1. Where are you currently experiencing pain?
Please check appropriate boxes:

lower back
leg
foot
neck
shoulder
arm

2. How long have you had this pain?
Please check appropriate box:
1-3 months
4-6 months
7-12 months
More than a year

3. Have you received a diagnosis from a physician for one of the following conditions: herniated disc, ruptured or bulging disc, degenerative disc disease, sciatica, pinched nerve, stenosis, or facet syndrome?
Yes     No

If Yes, which one(s):
Please check appropriate boxes:
herniated disc
ruptured or bulging disc
degenerative disc disease
pinched nerve
sciatica
spinal stenosis
facet syndrome

4. When was your most recent MRI or CT scan?
within the last 3 months
4 to 12 months ago
more than 1 year, but less than 2 years
over two years ago
haven’t had one

5. Have you received Chiropractic, Physical Therapy, or spinal injections for your condition?
Yes     No

6. Have you had low back or neck surgery
Yes     No

6a. If yes, what type of surgery:
lamenectomy
discectomy
fusion
other

6b. If “yes” above, do you have any hardware in your back like screws, rods or plates?
Yes     No

7. Have you been told that you might need spine surgery?
Yes     No

8. Have you been told “You might just have to live with some pain.”?
Yes     No

9. Do you have trouble doing daily activities such as walking, sleeping, bending?
Yes     No

10. Are you ready to stop hurting?
Yes     No

Your results will be e-mailed to you almost immediately.
To schedule a visit with Dr. Allen, just call 214-227-5155

And remember. The call is Free. The consultation is Free. The Evaluation is Free. You have nothing to lose but your Pain!