TREATMENT CHECK TOOL

Your condition

Your treatment

Your results

What condition do you have?

Cervical Radiculopathy Degenerative Disc Disease Herniated Disc Lumbar Radiculopathy Myelopathy Osteoporosis Sciatica Scoliosis Spinal Stenosis Spondylolisthesis Spondylosis

How long have you been experiencing pain?

1 Month or less 1 - 6 Months 7 - 12 Months 1 Year or more

Have you undergone any of the following studies?

CT Scan MRI Myelogram X-Ray Nerve Conduction Study Discogram Other None

If other, please explain:

How long ago was your last study done?

1 Month or less 1 - 6 Months 7 - 12 Months 1 Year or more

How long ago was your last study done?

1 Month or less 1 - 6 Months 7 - 12 Months 1 Year or more

What treatments have you tried?

Medication Chiropractic Care Massage Acupuncture Epidurals Physical Therapy Nerve Block Injections Cortisone Injections Other None

If other treatment, please explain

How effective is your current treatment?

Not Very Somewhat Very

How long does the treatment help with your pain?

1 - 7 Days 2 - 4 Weeks 2 - 3 Months 3 - 6 Months 6 - 12 Months More Than One Year

Have you been recommended for a specific treatment you have not yet undergone?

EMG Discogram Medication Chiropractor Acupuncture Physical Therapy Nerve Study Nerve Block Injections Cortisone Injections Other None

If other, please explain:

First Name

Last Name

Phone

Comments

CONTACT

(210) 802-4662

Info@TexasSpineCare.com

3619 Paesanos Pkwy, Suite 302
San Antonio, TX 78231

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