Request a Complimentary Consultation

Please Note: Fill out this form if you wish to receive further information regarding How To End Your Back Pain. Please check all spam and email filters for our emails and it is always best to leave a good contact number.
This consultation form is used to determine if you are a candidate for our Non-Surgical Decompression Therapy. This may also be used to schedule a consultation with Dr. Donaldson if you so choose. This is not meant to give you a diagnosis or prognosis and is for informational purposes. All information will be kept confidential. Please check ALL that apply.
Where is your symptom(s) located?	Neck Arm Wrist Fingers Low Back Buttocks Hip Thigh Leg Calf Foot Toes
Which best describes your pain?	Dull pain Sharp pain Throbbing pain Tingling Achy pain Shooting pain Burning pain Numbness
How long have you had your pain?	Four weeks or less Five weeks or more More than six months More than one year
What is the frequency of your pain?	Intermittent 0-25% of the day Occassional 26-50% of the day Frequent 51-75% of the day Constant 76-100% of the day
The pain is worse in the:	AM PM Both
Have you already contacted a doctor for this complaint?	Yes No
Have you been diagnosed with any of the following?	Herniated disc Bulging disc Sciatica Degenerative disc disease Stenosis Spondylolisthesis
Have you been clinically diagnosed with any of the following?	Osteoporosis Cancer High cholesterol High blood pressure Cancer Stroke Diabetes Abdominal aortic aneurysm
Have you had an MRI or CT scan of your spine?	Less than one year ago Les than two years ago Two or more years ago I have not had an MRI or CT scan
Have you had neck or back surgery?	Yes No
If yes, was there metal of any kind left in your spine? (For example: screws, plates, rods, etc.)	Yes No
Are you scheduled for neck or back surgery or injections?	I am scheduled for neck surgery I am scheduled for back surgery I am scheduled for injections No, I am not scheduled for surgery or injections
Has your pain or condition affected any of these activities?	Sitting Standing Sitting to standing Lying on back Sleeping Driving Walking Lifting Pushing Physical activities Lack of concentration None
Which of these activities aggravate your pain or condition?	Bending forward Bending backward Twisting right Twisting left Coughing Sneezing Bearing down while moving bowels
Have you been told you need to live with the pain?	Yes No
Have you been given a poor prognosis?	Yes No
When was the last time you were free from pain or discomfort for over a week?	Within one month More than one month ago More than six months ago More than one year ago More than five years ago More than ten years ago
If there is possibly a way to relieve your condition or pain with Non-Surgical and Non-Invasive Spinal Decompression, are you interested in scheduling a consultation with Dr. Donaldson?	Yes No
When is the best time to contact you to schedule a consult with Dr. Donaldson?	Morning Afternoon Evening
Name:
Age:
Email Address:
Phone number:
Street address:
City:
State:
Zip:

create web form