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IDD Pre-Qualifying Form
Spinal Decompression of Oklahoma
Fax: 918-341-7443
 

Pre-Qualifying Form For IDD Therapy

DO YOU SUFFER FROM BACK OR NECK PAIN?

Alternative to Surgery
IDD THERAPY HAS PROVEN RESULTS

Please complete the following form and click Submit. We will contact you as soon as possible regarding your results.


First Name *
 Last Name *
Daytime Phone *
 Evening Phone
Where is the pain located?
Neck (Cervical)   
Back (Lumbar)   
Rate your pain from 1-10 for the Average for the last week. (Example: 6/10)
Average
Most
Least
Has the pain affected your daily activities, work, etc.?
Do you have days without pain?
What X-Rays, MRI's, CT Scans, etc. have you most recently had?
X-Rays   
MRI   
CT Scan   
Discogram   
Other   
What have you done to relieve the pain in the past?
Physical Therapy    Chiropractic   
Exercise Rx    Accupuncture   
Massage Therapy    Other   
Are currently on any medication for the pain?
Loratab    Flexerill   
Hydrocodine/Codone    Morphine   
Other    None   
What surgeries have you had in relation to the pain? (Spinal related only)
Laminectomy    Discectomy, Spinal Fusion   
Percutaneous Laser Disc Decompression    IDET   
Other    None   
Do You Smoke?
Do you have weakness, tingling or burning pain into any extremity due to certain positions?
Right Arm    Right Hand    Right Fingers   
Left Arm    Left Hand    Left Finger   
Right Hip    Right Leg    Right Calf   
Right Foot    Right Toe(s)    Left Hip   
Left Leg    Left Calf    Left Foot   
Left Toe(s)   
Are you female and over seventy years of age?
If yes, have you had a recent (DEXA) bone scan?
Are you male and over seventy-five years of age?
If yes, have you had a recent (DEXA) bone scan?
Which Insurance Provider do you carry?
How did you hear about Spinal Decompression of Oklahoma?
Value News    Local Newspaper   
Magazine    Doctor   
Internet    Friend   
Other   
Surgery Explanation
Please Explain.

* Required to submit this form





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