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Is your problem a work related injury?
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If your predominant pain is neck related, please check the following if you have one or more of these symptoms:

Left arm pain, numbness or weakness
Right arm pain, numbness or weakness

If your predominant pain is low back related, please check the following
if you have one or more of these symptoms:

Left leg pain, numbness or weakness
Right leg pain, numbness or weakness

Do you have any of the following? Please check all that apply.

Osteophytes or Spurs? If so, how many levels

If your predominant complaint is thoracic (mid back pain)

Mid back pain

Have you had spine surgery? If yes, when, where, and who was the surgeon?

Have you seen a surgeon? What was recommended?

Have you had a MRI scan? If so, what is the impression or
summary at the bottom of the scan report?
(It is very important that you let us know the the entire summary
at bottom of your scan report.)

What tests and treatment have you had?

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