* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?    

    *Sex?       Male Female

If your client has a back disorder, please answer the following:

1.  When did your client first notice back comfort?   

2. How often does the pain  occur?  

3. Where is the pain located?      

4. Where does the pain extend to?     

5. How long does the pain last?     

6. What causes the pain?        

7. Is your client limited in any way due to back pain? 

8. Have your client ever missed work because of back pain?    Unknown Yes No

9. What was the actual diagnosis?   

10. Is your client on any medications?   Unknown Yes No

            If yes, please give details: