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Can We Help You?

Pain Questionnaire

The form below is dynamic and will change based on your input.   Please submit one questionnaire per pain complaint.

Health Questionnaire
Where are you having pain? (Select worst problem first, if you have more than one problem area, you'll need to complete a separate questionnaire)

Neck Pain Questions

Where is your neck pain? (check all that apply)
What is the level of your neck pain at its worst?
How did this pain begin?
Was your car accident within the last 2 months?
Do you have an attorney that is handling your car accident case?
Is the pain constant or does it come and go?
What helps reduce the pain? (check all that apply)
What increases the pain? (check all that apply)
How would you describe your pain? (check all that apply)
Have you experienced this same pain before?
Does your neck pain travel to other body parts?
Where does the pain travel to? (check all that apply)
What other doctors have you seen for your neck pain? (check all that apply)
Have you had any of the following procedures done to your neck? (check all that apply)
How effective do you feel the Trigger point injections were for your neck pain?
How effective do you feel the Dry Needling was for your neck pain?
How effective do you feel the Massage was for your neck pain?
How effective do you feel the Nerve Block was for your neck pain?
How effective do you feel the Epidural Steroid Injection was for your neck pain?
Have you had any diagnostic imaging of your neck done within the last year? (check all that apply)
Have you been diagnosed with any of the following? (check all that apply)
Have you been recommended for surgery on your neck?
Have you already had surgery on your neck?

Upper/Mid Back Pain Questions

Where is your upper/mid back pain? (check all that apply)
What is the level of your upper/mid-back pain at its worst?
How did this pain begin?
Was your car accident within the last 2 months?
Do you have an attorney that is handling your car accident case?
Is the pain constant or does it come and go?
What helps reduce the pain? (check all that apply)
What increases the pain? (check all that apply)
How would you describe your pain? (check all that apply)
Have you experienced this same pain before?
Does your upper/mid-back pain travel to other body parts?
Where does the pain travel to? (check all that apply)
What other doctors have you seen for this pain? (check all that apply)
Have you had any of the following procedures done to your upper/mid-back? (check all that apply)
How effective do you feel the Trigger point injections were?
How effective do you feel the Dry Needling was?
How effective do you feel the Massage was?
How effective do you feel the Nerve Block was?
How effective do you feel the Epidural Steroid Injection was?
Have you had any diagnostic imaging of your upper/mid-back done within the last year? (check all that apply)
Have you been diagnosed with any of the following? (check all that apply)
Have you been recommended for thoracic spine surgery?
Have you already had thoracic spine surgery?

Low Back Pain Questions

Where is your low back pain? (check all that apply)
What is the level of your low back pain at its worst?
How did this pain begin?
Was your car accident within the last 2 months?
Do you have an attorney that is handling your car accident case?
Is the pain constant or does it come and go?
What helps reduce the pain? (check all that apply)
What increases the pain? (check all that apply)
How would you describe your pain? (check all that apply)
Have you experienced this same pain before?
Does your low back pain travel to other body parts?
Where does the pain travel to? (check all that apply)
What other doctors have you seen for this pain? (check all that apply)
Have you had any of the following procedures done to your low back? (check all that apply)
How effective do you feel the Trigger point injections were?
How effective do you feel the Dry Needling was?
How effective do you feel the Massage was?
How effective do you feel the Nerve Block was?
How effective do you feel the Epidural Steroid Injection was?
Have you had any diagnostic imaging of your low back done within the last year? (check all that apply)
Have you been diagnosed with any of the following? (check all that apply)
Have you been recommended for lumbar spine surgery?
Have you already had lumbar spine surgery?

Summary

Dr Raymond Taylor Kennesaw GA

Hello, I'm Dr. Raymond Taylor, thanks for taking the time to fill out this form. Based on the information you provided, you appear to be a good candidate for care. My recommendation would be to have you come in for a free consultation. That way I can answer any questions you may have; and we can work on creating a game plan to resolve your spinal pain once and for all!
Are you ready to get started?
Hello, I'm Dr. Raymond Taylor, thanks for taking the time to fill out this form. Due to your spinal fusion surgery, I think it would be best to have you come in for a free consultation. My treatment options are more limited because of your surgery, however, there are still many different ways I may be able to help you.
Hello, I'm Dr. Raymond Taylor, thanks for taking the time to fill out this form. Due to your spinal laminectomy, I think it would be best to have you come in for a free consultation. As long as the laminectomy was performed without any hardware being installed in your spine, I have lots of options to help you feel better.
Hello, I'm Dr. Raymond Taylor, thanks for taking the time to fill out this form. Due to your spinal laminotomy, I think it would be best to have you come in for a free consultation. As long as the laminotomy was performed without any hardware being installed in your spine, I have lots of options to help you feel better.
Hello, I'm Dr. Raymond Taylor, thanks for taking the time to fill out this form. Due to your microdiscectomy surgery, I think it would be best to have you come in for a free consultation. I have lots of treatment options to help you feel better.
Hello, I'm Dr. Raymond Taylor, thanks for taking the time to fill out this form. Due to the limitations of this form, I know you've had spinal surgery, but I don't know which until I can review your actual answers myself. My recommendation is to have you come in for a free consultation. That way we can discuss in more detail your circumstance and I can get a better idea of what treatment options I can use to help you.
Would you like to schedule a free consultation with me to answer any questions you may have; and work on creating a game plan to resolve your spinal pain once and for all?
No problem, I'm not offended if you don't want to meet with me. I know there are clinics out there that use high pressure sales pitches to strongarm patients into care. Not here. Not even close. I'm glad to sit down with you, review your situation and I will give you my honest opinion on whether or not I think I can help you. That's it, no strings attached and no pressure!
Fantastic! I look forward to meeting you soon. Please fill out your name below and click SUBMIT so I can match up your records.
Fantastic! I look forward to meeting you soon. Please fill out your contact information below and click SUBMIT so we can reach out and schedule your consultation.
No problem, I hope that you're able to find someone that can help you. Living with pain can be quite horrible. Best Wishes, Dr. Taylor

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Thank you for filling out this form. Click the SUBMIT button below and someone from our clinic will reach out to you ASAP to schedule your free consultation.

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