DTS online Registration
Az Spinal Decompression Center
You have been qualified for a consultation with Dr. Sanders-Shochat, chiropractor. This however does NOT mean that your case has been accepted.
Your consultation today will determine if:
A) You are a legitimate candidate for this program and
B) Your condition is serious enough to warrant your case being accepted for treatment.
Name Age
Birthday Address
Sex Male  Female
City Province
Postal Code Home Phone
Work Phone Cell Phone
Best Place To Reach You Home WorkCell May we leave a voice mail message for you? Yes  No
Employer Occupation
Marital Status Single      Married      Divorced      Widowed
Spouses Name SIN#
I consent to allow the Doctor to speak with me and perform an examination (if necessary) in order to determine if I am a good candidate for non-surgical Spinal Decompression and also to determine if he is willing to accept my case.
How Did You Hear About Az Spinal Decompression Center? How Serious Do You Think Your Problem Is?- (Scale 1-5)
What Is Your Main Problem/Symptom Prompting Your Request For A Consultation With The Doctor? Back      Neck      Other
Would You Consider This Problem ... MINIMAL (Annoying but causing NO limitations)
SLIGHT (Tolerable but causing a little limitation)
MODERATE (Sometimes tolerable but definitely causing limitations)
SEVERE (Causing Significant limitations)
EXTREME (Causing near constant (>80% of the time) limitations)
1. In spite of the fact that you are not a back specialist, you are in fact the person who knows more about your back than anyone else. In your own words and in your own opinion what do you think the real problem is?
2. What are you hoping happens today as a result of your consultation with the Doctor?
3. Since your back pain became this severe what three things has it caused you to miss the most?
4. How long have you been like this?
5. How has your life changed since your back and/or neck became a problem?
6. What activities are you limited in?
7. What kinds of treatments have you received?
Epidural  : How Many When (approx)
Physical Therapy  : How Long When (approx)
Medication  : When (approx)
Surgery  : Type When (approx)
Other  :
8. When did you receive these treatments and for how long?
9. Did any of these treatments work? If so which one(s)? For how long?
10. Is there anything you can do that makes it feel better?
11. What activities/movements are guaranteed to make it worse?
12. Please describe the quality of the pain. (Sharp, Dull, achy, toothache, shooting, stabbing, numb, tingling, etc…)
13. It is worse in the morning or is it worse as the day progresses?
14. If you cannot find a solution to this problem what do you think will happen to you?
15. What are you hoping the Doctor tells you today?
16. Describe what you hope or think he might be able to do for you.
17. Describe what will be different in your life if you can get better.
18. When is the VERY FIRST time you recall having this problem?
In Reference To Your MAIN PROBLEM How Often Are You Aware of This Problem? Occasionally (25% of the time)
Intermittently (50% of the time)
Frequently (75% of the time)
Constant (90-100% of the time)
Due To Your Main Problem…..
Have You Lost Any time From Work? Yes No
How Much Time and What Tasks Have Been Limited?
Have You Lost Any Time From Your Chores/Tasks At Home? Yes No
How Much Time and What Tasks Have Been Limited?
Have You Lost Any Time From Your Family? Yes No
How Much Time and What Tasks Have Been Limited?
Have You Lost Any Time From Your Leisure Activities? (Hobbies, Travel, Sports, etc…)
How Much Time and What Tasks have Been Limited?
Considering the amount of pain/discomfort you’ve had THIS week, how long has your problem been this severe?
On a Scale of 0-10 (10 being unbearable, 0 being No pain or Discomfort) Please rate the following…
The HIGHEST your pain gets WITHOUT medication
The LOWEST your pain gets WITHOUT medication
The HIGHEST your pain gets WITH medication
The LOWEST your pain gets WITH medication
List ANY surgeries that you have had and the corresponding dates.
Have you had ANY of the following in the last 12 months or currently. (Mark C for Current. X for in last 12 mos.)
GENERAL
Chills C   X Convulsions C   X Dizziness C   X
Fainting C   X Fatigue C   X Fever C   X
Headache C   X Loss of sleep C   X Numbness in BOTH
hands AND feet
C   X
Loss of Weight C   X Nervousness C   X Wheezing C   X
Bronchitis C   X Allergy C   X (to what)


CARDIOVASCULAR
High Blood Pressure C   X Low Blood Pressure C   X Pain over heart C   X
Poor Circulation C   X Rapid Heartbeat C   X Slow Heartbeat C   X
Previous Heart Problem C   X (Describe) Stroke C   X
TIA C   X Swollen Ankles C   X Varicose Veins C   X
Aortic Aneurysm C   X Bruise Easily C   X


DISEASES/CONDITIONS
Appendicitis C   X Anemia C   X Arthritis C   X
Alcoholism C   X Abdominal Surgery C   X Bleeding Disorder C   X
Blood Clot(s) C   X Breathing difficulty C   X Cancer C   X
Cholesterol High C   X Colon Problems C   X Diabetes C   X
Depression C   X Epilepsy C   X Eczema C   X
Eating Disorder C   X Glaucoma C   X HIV+ C   X
Heart Disease C   X Hernia C   X Headaches C   X
Influenza C   X Kidney Disease C   X Liver Disease C   X
Low back Pain C   X Mental Illness C   X Measles C   X
Mumps C   X Pleurisy C   X Pneumonia C   X
Polio C   X Prostate Problems C   X Hyperthyroid C   X
Hypothyroid C   X Rectal Surgery C   X


EARS/EYES/NOSE/THROAT
Asthma C   X Crossed Eyes C   X Double Vision C   X
Blurred Vision C   X Dificulty Swallowing C   X Deafness C   X
Hearing Loss C   X Ear Pain C   X Thyroid Problem C   X
Nose Bleeds C   X Sinus Problems C   X Sore Throats C   X


GASTRO-INTESTINAL
Gas C   X Colon Trouble C   X Constipation C   X
Diarrhea C   X Gallbladder Trouble C   X Hemorrhoids C   X
Liver Trouble C   X Nausea C   X Stomach Ache C   X
Poor Appetite C   X Poor Digestion C   X Vomiting C   X
Vomiting Blood C   X Rectal Bleeding C   X Bloating C   X


GENITO-URINARY
Blood in Urine C   X Frequent urination C   X Inability to control urine C   X
Kidney Infection C   X Painful Urination C   X Prostate Trouble C   X
Painful Urination C   X


FOR MEN ONLY
Lump in testicles C   X Penis discharge C   X


FOR WOMEN ONLY
Menstrual Cramps C   X Excessive menstrual flow C   X Hot Flashes C   X
Irregular Cycle C   X Painful periods C   X Birth Control Pills C   X
Abnormal Pap smear C   X


MUSCLE/JOINT BONE
Backache C   X Foot Trouble C   X Pain Between Shoulders C   X
Painful Tailbone C   X StiffNeck C   X Spinal Curvature C   X
Swollen Joints C   X


NEUROLOGIC
Seizures C   X Dizziness C   X Hand Trembling C   X
Weakness C   X Difficulty with speech C   X Loss of memory C   X
Loss of coordination C   X


RESPIRATORY
Chest pain C   X Chronic Cough C   X Difficulty Breathing C   X
Coughing/Spitting Blood C   X