Let’s get started!

1. Have you been diagnosed by a Physician with any of the following conditions?

Degenerative Disc Disease
Herniated/Bulging/Extruded Disc
Spinal Stenosis
Sciatica
Facet Syndrome
I have not been evaluated by a doctor
None of the above – My Doctor diagnosed me with:

2. How often do you notice your pain?

Never
Up to several times per week
I feel my pain daily
My pain never really goes away

3. How intense is the pain that you are currently suffering from?

I have no pain
I have mild pain (1 to 3 of 10 on pain scale)
I have moderate pain (3 to 6 of 10 on pain scale)
My pain is severe (7/+ or 10 on pain scale)

4. Does your condition limit your ability to sit/stand for any amount of time?

No it never limits my ability
Some of the time
Most of the time
All of the time

5. Does your condition keep you from doing normal activities in your life? I.e. the ability to drive your car for more than short distances, performing your normal job duties, recreational activities, etc.

No, my normal daily activities are not affected by my condition.
Occasionally my condition keeps me from my daily activities.
My condition FREQUENTLY keeps me from my daily activities.
I am basically disabled and can’t perform many of my recreational / work activities.

6. Does your pain travel from your low back or neck into your extremities?

No it doesn’t travel – it stays in one place
My pain travels into my Hips/Buttocks or Shoulders/Upper Back
My pain travels into my Mid Thigh/Knee or Arms
My pain travels into my Feet/Toes or Hands/Fingers

7. Do you experience Numbness or Tingling in your extremities?

No I don’t notice any numbness or tingling
I feel tingling/numbness into my Hips/Buttocks or Shoulder/Upper Back
I feel tingling/numbness down to my Mid Thigh/Knee or Arms
I feel tingling/numbness into my Feet/Toes or Hands/Fingers

8. Do you have Weakness or Loss of Muscle Function in your extremities?

No I don’t have any muscular weakness or loss of function
My condition is causing muscle weakness or atrophy
My condition is causing me difficulty in movements. I.e. limping, hunching over for extended periods, etc.
My condition is severe enough to where I can’t raise my hands or feet voluntarily. A.K.A. foot drop.

9. Do any of the following apply to you? Click all that apply.

I am pregnant
I’ve undergone a spinal surgery where metal, titanium rods, or fusion cages were implanted.
A physician has diagnosed me with a Grade II or higher Spondylolisthesis
A physician has diagnosed me with Ankylosing Spondylitis
I have a confirmed Abdominal Aortic Aneurysm
I am currently undergoing treatment for Pelvic, Metatastic or Abdominal Cancer