Utilize this form for a free preliminary review of your MRI records. This free review does not constitute as a medical evaluation by our physicians but can help us to determine whether or not we believe that we might be able to assist you. Please either fax this form along with your MRI report to 850-892-4212 or by regular mail: 101 MicroSpine Way, DeFuniak Springs, FL 32435.

Please fill in pain diagram below with the following:     Name:_______________________________ 
Pain                               xxxxxxxx                              Phone: ______________________________
Aching                           - - - - - - - - -                      Email: _______________________________
Burning                          111111111111                    Address:_____________________________
Pins and Needles            ooooooooooo                     City: _______________State_____Zip______
Numbness                     nnnnnnnnnnn                         Sex: M/F________DOB___/____/____

On a scale from 0 - 10, circle the level of your pain:  0     1     2     3     4     5     6     7     8     9     10
Circle the appropriate Information Below:
Where is your Worst pain? Neck / Arms / Headache / Torso / Mid Back / Low Back / Buttocks / Legs
Second worst pain (if applicable)? Neck / Arms / Headache / Torso / Mid Back / Low Back / Buttocks / Legs
Describe Your Pain: ___________________________________________________________ 
Have you had spine surgery previously? Y / N, and if yes, what was performed on you? ____________________________________________________________________________
What treatments have you had for this condition? Pain management / P.T./ Chiropractor
Briefly describe what was done by the above:_______________________________________
Any Significant Health Problems that might affect surgery? ___________________________