Spinal Decompression Multistep Form | Butler Pain Relief

Step 1 of 9

Complete This Survey To Discover If Our Spinal Decompression Protocol Treatments Are Right For You.

Before we begin, please provide your contact information.

If you are a good candidate for our spinal decompression protocols, one of our team members will contact you within one business day.

Step 2 of 9

Spinal Decompression Protocol Survey

Which of the following symptoms are you currently experiencing?

Please select all that apply.

NumbnessTinglingBurning SensationMuscle WeaknessPain

Step 3 of 9

Spinal Decompression Protocol Survey

Where is your pain located?

Please select all that apply.

Left sideRight SideBoth SidesHipLegAnkle/Foot

Step 4 of 9

Spinal Decompression Protocol Survey

Duration of Condition:

How long have you been experiencing your symptoms?

0-1 Years1-2 Years2-5 Years5-10 Years10+ Years

Step 5 of 9

Spinal Decompression Protocol Survey

Severity of Condition:

On a scale of 1-10 How would you rate the severity of your symptoms?

12345678910

Step 6 of 9

Spinal Decompression Protocol Survey

Previous Treatments:

What have you done in the past to treat your pain?

Please select all that apply.

MedicationLifestyle ChangesPhysical TherapyTensChiropractic careSurgeryOther

Step 7 of 9

Spinal Decompression Protocol Survey

On a Scale of 1 – 10 with 1 being the lowest level of success and 10 being the highest, How well have you been able to manage your symptoms with your past treatments?

12345678910

Step 8 of 9

Spinal Decompression Protocol Survey

Treatment Goals and Expectations:

What are your primary goals and expectations from a treatment for pain?

Please select all that apply.

Pain or symptom reductionImproved mobilityReducing medication reliance

Step 9 of 9

Spinal Decompression Protocol Survey

Comments and concerns:

Is there any additional information you would like to share with the Doctor before we contact you?

‍"By Clicking this box you give consent to be contacted by Discover Wellness Center via SMS Texting, Email, and Phone"

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