Discforce.com

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Free Online Consultation

Here's your chance for a mini-consulation with one of our specialist. If you fill out this form and submit it, we will write or call you back with our opinion. Please be as truthful and accurate as possible. The materials herein will be kept private. However you the patient allow Disc Force to review and utilzie this data and release them from any HIPPA statues.

PHONE: (866) 57-FORCE (36723)

Fields marked (*) are required

First Name:*

Last Name:*

Email:*

Sex (Male or Female):*

Age:*

Address:

City:

State:

Zip:

Where Does it hurt?
(Check all the areas that are painful):*
Head
Face
Wrist
Hand
Forearm
Neck
Abdomen
Shoulders
Pelvis
Middle Back
Lower Back
Knees
Hips
Thighs
Chest
Shins
Arm
Elbow
Ankle
Feet

Describe the most painful area:*
(use a 0-10 pain scale, 0 being not painful and 10 being excruciating)

When did it start, and what makes it better or worse:*

The reason for treatment is due to a:*
Work
Auto
Athletic
Progressive
Unknown

Describe any condition that may be related
to your pain such as your general health:

Would you prefer our response to be by
phone or e-mail:*
Phone
Email

Please leave your e-mail or phone number
so we can respond:

Describe treatments you have received and
medications that you are taking:*

Do you have any of the following:
(if you don't know what it is, do not check the box)
Aortic Aneurysm
Spondylolisthesis
Moderate to Severe Osteoporosis
Pregnancy
Lumbar Spinal Fusion or Metal Hardware
Spinal or Pelvic Cancer
A Recent Low Back Fracture
Connective tissue
Believe