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Email: info@sdspineinstitute.com

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Where is your pain? (choose all that apply)	Back Neck Arm/Hands Legs/Feet
Have you been in pain for more than 6 months?	Yes No
Have you been diagnosed with any of the following conditions? (choose all that apply)	Spondylolisthesis Stenosis Herniated Disk Sciatica Radiculopathy Degenerative Scoliosis Myelopathy Kyphosis Flackback Syndrome Spinal Infection Spinal Tumor Ankylosing Spondylitis Adjacent Segment Disease
What treatments have you had so far? (choose all that apply)	Physical Therapy Injections Surgery
Have you been told you need surgery?	Yes No
Are you interested in having a minimally invasive surgical treatment?	Yes No

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