• Chronic and Acute                     Neck & Back Pain
• Disc Herniations
• Spinal Arthritis
• Degenerative Disc Disease
• Failed Back Surgery
• Spinal Stenosis
• Sciatica
• Carpal Tunnel Syndrome
• Facet SyndromeSports Related Injuries

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“This was the best decision of my life!  I completed my treatment and I can now pick things up off the floor, put my socks on in the morning, swing a golf club again, go for walks... all PAIN FREE!...”

- John Weeks - Patient

Patient Application

Thank you for choosing the Toronto Spine & Sports Clinic. Please fill out the following as thoroughly as you can so that we can get some back ground information about your condition.

When you attend your appointment, please bring any medical records that you have (old and new) that is related to your condition. Such medical reports include, MRI/CT/X-Ray reports, Films, CD discs, etc.

Copies of MRI, CT and X-Rays can be picked up from the facility that you had them taken and reports can be given to you by your family doctor.

* Required

First Name *	Last Name *
Email Address *	Phone Number *
Sex * Male Female	Age: *
How did you hear about our clinic? Medical doctor Health care professional Former patient Internet News TV   Radio Print Drive By
Is your pain localized to your neck/back or does it radiate down your arms/legs? (check what applies) Neck Only Neck and arms Lower back only Lower back and legs
How long have you been suffering? -- Please select -- Less than 1 year 2-3 years 5-10 years 10-15 years 15 + years	Rate your pain (0= no pain, 10= unbearable /incapacitating pain)
Related symptoms Neck Pain Lower back Pain Digestive Problems Headaches Sciatic pain Weak Bladder Dizziness Numbness/tingling in leg(s) Weak Bowels Ringing in ears (Tinnitus) Burning in leg(s) Balance Problems Leg weakness Burning in arms/hands Hip Pain Tingling in hands leg/foot incoordination Hand/arm weakness Groin Pain Hand/Arm incoordination Erectile Dysfunction
How often are you aware of your problem/pain? -- Please select -- Rarely (up to 25% of the time) Occasionally (50% of the time) Frequently (75% of the time) Constantly (90% + of the time)	How is your pain progressing -- Please select -- Pain is getting better Staying the same Getting worse Getting worse faster
When is your pain at it’s worst? -- Please select -- Morning Afternoons Nights My pain never goes away
What activities tend to make your problem worse?	How has your pain Impacted your life (family, social, work etc.)?
Are you on any medication? * Yes No	If you are on medication, what?
Have you ever had spinal surgery? * Yes No	If you have had spinal surgery, when?
If you have had spinal surgery, what was the procedure?	Did you consider the surgery a success? Yes No Somewhat
Do you have a history of Cancer (including bone cancer)? Yes No	Have you ever been told that you have and Antereolithesis? Yes No
Any history of aneurysm? Yes No
Anything else that you believe is noteworthy?	What are you hoping for at your visit with the our doctor?
Is the pain something that you can live with or you wanted addressed immediately?
Enter Word Verification in box below *