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8573 E Princess Dr Suite 221, Scottsdale AZ 85255
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Symptoms
Have you lost significant control of Bowel or Bladder function?
Do you have constant night sweats, or unexplained weight loss or loss of appetite?
Have you been referred from another Orthopaedic, Spine or Neuro Surgeons?
Have you ever smoked tobacco products?
Have you been told by a Physician that you have a fractured vertebra? If so, what level?
For Neck Pain Patients Only
Do you have neck pain?
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Do you have arm pain?
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No
If “yes” to both above, which pain is worse, Neck or Arm? Enter percentage.
Neck
Arm
Numbness or clumsiness in the hands?
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Do you frequently have difficulty walking, stumble or fall?
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For Low Back/Leg Pain Patients Only
Do you have back pain?
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Do you have leg pain?
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If “Yes” to both above, which pain is worse, back or leg? Enter percentage.
Back
Leg
Do you have numbness or tingling anywhere? If so, where?
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No
Conservative Medical Management (CMM)
Have you had regular spine x-rays in the past 6 months?
Yes
No
Have you had an MRI or CT scan in the past year?**
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No
Have you completed a course of spine physical therapy in the last 9 months?
Yes
No
Have you tried anti-inflammatory for your spine in the last 3 months?
Yes
No
Have you tried Narcotics for your spine in the last 3 months?
Yes
No
**All images must be brought in by the patient on an disc before or by the time of the appointment
Appointment Information
Appointment Date Requested
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How long has the problem been present?
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