Sciatica - Multistep Form

Step 1 of 12

Complete This Survey To Discover If Our Sciatica Protocol Treatments Are Right For You.

Before we begin, please provide your contact information.

If you are a good candidate for our sciatica protocols, one of our team members will contact you within one business day.

Step 2 of 12

Sciatica Pain Protocol Survey

Which of the following sciatica symptoms are you currently experiencing?

Please select all that apply.

Step 3 of 12

Sciatica Pain Protocol Survey

Where is your sciatica pain located?

Please select all that apply.

Step 4 of 12

Sciatica Pain Protocol Survey

Duration of Condition:

How long have you been experiencing your symptoms?

Step 5 of 12

Sciatica Pain Protocol Survey

Severity of Condition:

On a scale of 1-10 How would you rate the severity of your symptoms?

Step 6 of 12

Sciatica Pain Protocol Survey

Previous Treatments:

What have you done in the past to treat your sciatica pain?

Please select all that apply.

Step 7 of 12

Sciatica Pain Protocol Survey

On a Scale of 1 – 10 with 1 being the lowest level of success and 10 being the highest, How well have you been able to manage your symptoms with your past treatments?

Step 8 of 12

Sciatica Pain Protocol Survey

Treatment Goals and Expectations:

What are your primary goals and expectations from a treatment for sciatica pain?

Please select all that apply.

Pain or symptom reductionImproved mobilityReducing medication reliance

Sciatica Pain Protocol Survey

Step 9 of 12

Treatment Goals and Expectations:

What day of the week is the best for someone on our staff to contact you?

Please select all that apply.

Sciatica Pain Protocol Survey

Step 10 of 12

Treatment Goals and Expectations:

What time of day is the best for someone on our staff to contact you?

Please select all that apply.

Sciatica Pain Protocol Survey

Step 11 of 12

Comments and concerns:

Is there any additional information you would like to share with the Doctor before we contact you?

Sciatica Pain Protocol Survey

Step 12 of 12

Someone from Specific Health Chiropractic and Neuropathy will be contacting you from 651-415-0418 regarding your survey and to help you with scheduling an appointment. We can't wait to speak with you!

By Clicking this box you give consent to be contacted by Specific Health Chiropractic via SMS Texting, Email, and Phone