Initial Inquiry Form – Back Institute Neurosurgery

---- The problem started when?

---- Have you had chiropractic treatments?

---- Has patient seen a surgeon for a present problem? What was recommended?

---- What tests and treatment has patient had?

---- Where and when did you have your latest MRI scan?

---- Are you going to have your MRI scan report faxed to our national receiving fax at 310-659-8869? (Attn: Dr. David Ditsworth, Chief of Neurosurgery)

---- Describe your usual sport activities before your spine problem:

---- Are you able to do any sport activity now? Describe:

---- Do you or did you stress your back in your work?

---- Describe your work?

---- Job Title now (or when you were working)

---- Where did you hear about us

---- What would you like to ask us?

---- If you have a google account, enter your google email address

---- Insurance Company Name

---- Insurance Type