1 Your Pain 2 Your Information Step 1: Tell us a bit more about your symptoms and pertinent health history. This will help our surgeons better determine if you are a candidate for minimally invasive spine surgery. PAIN ASSESSMENT - Please select the option below that indicates your pain level.* Please Select One 0 - No Pain 1 2 3 4 5 6 7 8 9 10 - Worst Pain Imaginable Check the following descriptions if they apply to your symptoms: (Check ALL that apply) Ache Burning Sharp Throbbing Shooting Shock like Spasms Numbness Weakness Tingling Pins and Needles Other If Other, please specify What makes it worse? (Check ALL that apply) Standing Walking Sitting Coughing Bending forward Bending backwards Other If Other, please specify 1. How did the symptoms start: * Motor vehicle accident Work injury Chronic Wear & tear Other personal injury Describe personal injury 2. When did your symptoms start: * Less than 6 months ago Less than 1 year ago Less than 2 years ago Less than 3 years ago Over 5 years ago 3. Have you been given any diagnoses? * Yes No Please tell us what diagnosis have you been given 4. Have you had any diagnostic testing done? MRI CT scan Bone scan Xray Electromyogram and Nerve conduction study EMG/NCS Other MRI - When? CT Scan - When? Bone Scan - When? Xray - When? EMG/NCS - When? Other - Please describe. When? 5. What treatments have you had: (Check ALL that apply) Spinal injections Surgery When did you get the spinal injections? How many Spinal injections have you received? What kind of Spinal Surgery have you had? How many Spinal Surgeries have you had? Optional - Please share any other information that you would like to convey to one of our surgeons to help us better evaluate your candidacy for minimally invasive spine surgery Step 2 Name* Age* State* Country* Home Phone Cell Phone Best Time to Call Email* Enter EmailConfirm Email How did you hear about us Word of mouth Online - Google Online - Bing Online - Yahoo News paper Mobile search Radio commercial Television ad Other Please specify Insurance: Spine Institute Northwest will work with you and/or your insurance to make our services as affordable as possible and keep your costs to a minimum! Please Select One Private Personal injury insurance (Motor vehicle incident or other) Self Pay Care Credit Other PRIVATE - Spine Institute Northwest works with many Private insurance companies. When the time comes to look into your coverage under your plan, our reimbursement specialists will evaluate each situation on a case by case basis and do our best to work with your insurance provider to keep your costs to a minimum. WORKERS COMPENSATION - Spine Institute Northwest works with private workers compensation. We recommend that you obtain pre-approval of surgery prior to entering our treatment programs. PERSONAL INJURY INSURANCE - Spine Institute Northwest works with many type of insurers. We accept assignment of benefits and insurance liens. Our patient advocates and reimbursement specialists are always ready to assist you for best results. MEDICARE, MEDICARE + SUPPLEMENTAL - Payments for spine surgery are excluded from outpatient ambulatory surgery center by Medicare. We do however have a special program for individuals on Medicare and financing options to fit most people’s needs. We will work with you to make our services as affordable as possible. For your convenience, your Spine care could be expedited by extension of credit through Care Credit upon completion of qualifying application. SELF PAY - Spine Institute Northwest has helped many individuals on a self pay basis. We offer flexible monthly payments and have affordable financing options to fit most people’s budgets. We will work with you to make our services as affordable as possible. If Other, please specify Additional Comments (optional)
