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A preliminary diagnosis is a few keystrokes away. Our surgeons and pain management specialists will use the info you enter to assist you in finding effective treatment options.
DISCLAIMER: If you are experiencing a medical emergency, please call 9-1-1. This form is for appointment requests only.
Appointment Details
Where is your pain located?
Foot
Hip, Buttocks, or Legs
Joints (wrists, elbows, knees, ankles, etc.)
Lower Back/Spine
Middle Back/Spine
Neck
Other
Shoulders or Arms
Where is your pain located?
Where is your pain strongest?
Foot
Hip, Buttocks, or Legs
Joints (wrists, elbows, knees, ankles, etc.)
Lower Back/Spine
Middle Back/Spine
Neck
Other
Shoulders or Arms
Where is your pain strongest?
How long have you experienced this pain?
How long have you experienced this pain?
1 month or less
1 year or more
1-6 months
7-12 months
How would you describe the pain?
Burning
Cramping
Numbness or tingling
Radiating or throbbing
Sharp
Shocking (quick jolts of pain)
How would you describe the pain?
Are you always in pain?
Are you always in pain?
No, it comes and goes depending on what activity I'm doing or what position I'm in.
Yes, I'm in constant pain that may worsen depending on the activity I'm doing.
When is your pain at its worst?
In the morning after waking up
While bending backward
While lying down
While performing strenuous activity
While sitting
While standing or walking
When is your pain at its worst?
When does your pain lessen or disappear?
In the morning after waking up
While bending backward
While bending backward
While lying down
While performing strenuous activity
While sitting
While standing or walking
When does your pain lessen or disappear?
What caused your pain or injury originally?
Leaning forward
Lifting something heavy
Not sure
Other
Slip or fall
Traumatic Injury
Vehicle crash or accident
What caused your pain or injury originally?
Have you been diagnosed with a specific condition?
Have you been diagnosed with a specific condition?
No, I have not been diagnosed by a physician
Yes, I've been diagnosed by a physician
Have you undergone any of the following?
CT Scan
MRI
Myelogram
Nerve Conduction Study
None of the above
Other
Viscogram
X-Ray
Have you undergone any of the following?
Patient Contact Information
First name
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Last name
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Email
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Email
1
No email
Phone number
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Phone type
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Select type
Home
Mobile
Work
Patient Insurance
Insurance Type
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Insurance Type
HMO
LOP
Medicaid
Medicare
PIP
PPO
Self-pay
Worker's Comp
Appointment Preferences
Preferred location
Select location
Glen Rock, NJ
Union, NJ
Clifton, NJ
East Orange, NJ
Elizabeth, NJ
Jersey City, NJ
Perth Amboy, NJ
Plainfield, NJ
Summit, NJ
West New York, NJ
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