Contact Us to Find Out if Non-Surgical Spinal Decompression is Right for You

If you are suffering with sciatica, herniated or bulging discs, degenerative disc disease, or chronic low back and leg pain, then non-surgical spinal decompression may be just what you're looking for. Please fill out and submit this Consultation Form or call our office at 631-673-2900.

Please Note: Only fill out this form if you are ready and willing to have a complimentary consultation. This Consultation form is used to determine if you are a candidate for this revolutionary technology called Non-Surgical Spinal Decompression Therapy. This will also be used to schedule a consultation with Dr. Picard if you so choose. This is not meant to give you a diagnosis or prognosis. The Consultation form is for educational purposes only. Please check ALL that apply.

Where is (are) your symptom(s) located?

How long have you had the pain?

Four weeks or less	Five weeks or more
Four weeks or less	Five weeks or more

Which best describes your pain?

Dull pain	Sharp pain	Throbbing pain	Tingling
Achy pain	Shooting pain	Thigh	Numbness

What is the frequency of the symptoms?

Intermittent 0-25% of the day	Occasional 26-50% of the day
Frequent 51-75% of the day	Constant 76-100% of the day

Both

Have you already contacted a doctor for this complaint?

Yes

Have you been diagnosed with any of the following?

Herniated Disc	Degenerative Disc Disease
Stenosis	Sciatica
Spondylolisthesis	Bulging Disc

Have you been clinically diagnosed with:

Have you been clinically diagnosed	Osteoporosis
Cancer	High Colesterol
Heart Disease	High Blood Pressure
Stroke	Abdominal Aortic Aneurysm
Diabetes

Have you had an MRI or CT?

Less than two years ago

Two or more years ago

I have not had an MRI or CT

Have you had neck or back surgery?

Neck

Back

Was there metal of any kind left in your spine?

Yes

Are you scheduled for neck or back surgery?

Yes

My Pain and or Condition has affected these activities:

My pain is aggravated by:

Bending forward	Twisting right
Coughing	Bearing down by moving bowels
Bending backward	Twisting left
Sneezing	Numbness

Describe how you feel when the pain is at its worst?

Have you been given a poor prognosis

Yes

Have you been told you need to live with the pain ?

Yes

When was the last time you were free from pain

Within 1 month	More than 1 month ago
More than 6 months ago	More than 1 year ago
More than 5 years ago	More than 10 years ago

Are you interested in scheduling a consultation?

Yes

When is the best time to contact you?

Morning

Afternoon

Evening

Please Send My Free Report To:

First Name:
Last Name:
E-mail Address:
Phone:
Mailing Address:
City:
State:
Zip Code:

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Huntington-Spinal-Decompression.com
182 Main St Huntington, NY 11743
Tel: 631.673.2900
Also Visit: drpicard.com

Neck	Fingers	Hip	Calf
Arm	Low Back	Thigh	Foot
Wrist	Buttocks	Leg	Toes

Sitting	Lying on Back
Walking	Physical Activities
Standing	Sleeping
Lifting	Lack of Concentration
Sitting to Standing	Driving
Pushing	None