ONLINE  CONSULTATION  FORM

The following form is made available to anyone who would like feedback about their current condition.  It is also available for patients, so that DeMent Family Chiropractic can track your progress.  Please complete all questions to the best of your ability and click the "Send Information" button at the bottom of this page.  Please remember to choose "Attention Dr. Scott" or "Attention Dr. Melody" in the pull down menu near the top of this page.


Your Name:          Your Phone: 


Attention:          Your Email: 


1.   Where is/are the area(s) of your current primary pain(s)?  Select those that apply.

Headaches:

Neck:

Upper Back:

Shoulders:

Lower Back:

Buttocks:

Hip:

Leg:




2.   How long have you been experiencing the pain?  Select one or fill in the number of years.

Less than a month:

More than a month:

More than 6 weeks:

More than 1 year:

    Number of years: 


   3.   Which most closely describe your pain(s)?  Select those that apply.

Dull:

Sharp:

Shooting:

Throbbing:

Burning:

Tingling:

Numbness:



   4.   Which best describes the frequency of your pain?  Select one that applies.

Intermittent (0-25% of the day):

Occasional (26-50% of the day):

Frequent (51-75% of the day):

Constant (76-100% of the day):



   5.   Which activities has your condition and pain effected?  Select those that apply.

Pain Sitting:

Trouble Walking:

Decreased Pace:

Pain Standing:

Trouble Driving:

Decreased Activities:

Trouble Lifting:

Interrupted Sleep:

Decreased Concentration:



   6.   Do any of the following activities aggravate your symptoms?  Select those that apply.

Bending Forward:

Bending Backward:

Coughing:

Sneezing:

Twisting:

Straining:

Pushing:

Pulling:

Rising:

Lying on Back:



   7.   Have you previously contacted another doctor about your pain?

Yes:

If yes, which type? 

No:

   8.   Have you had an MRI?

Yes:

No:

          


   9.   Have you had back surgery?

Yes:

No:

          
   10.   Are you scheduled for surgery?

Yes:

No:



   11.   Have you been diagnosed with any of the following?  Select those that apply.

Herniated Disc:

Disc Bulge:

Facet Syndrome:

Stenosis:

Degeneration:

Sciatica:

Spondylolisthesis:

Other(s): 



   12.   When is the pain worse?

Morning:

Midday:

Evening:

   13.   Has anyone told you that you have to learn to live with the pain?

Yes:

No:



   14.   When was the last time you felt really great?
   15.   How has your condition effected your life?

 

 


   16.   If there was a way to help without drugs or surgery, would you like to come in for a free consultation?

Yes:

No:

 
   17.   When is the best time to contact you?

Morning:

Midday:

Evening:

Email Only:



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