Help Me Now

Please provide the following information to book your appointment. After the questions, you have an option to book directly online. Alternatively, leave it up to us. We will contact you within 12 hours on a business day.

First Name *

Last Name *

Date Of Birth *

How did you find out about BackSpace?

Have you seen a specialist for your current condition?

YesNo

Have you had any treatment for this condition?

YesNo

Please specify what treatment you have had:

SurgeryInjectionsRehabilitationOther

Where are your symptoms? *

NeckArmBackLeg

Is your pain the result of a car accident, fall or crush injury?

YesNo

Was an ambulance called?

YesNo

Did you present to the emergency room within 48 hours of your accident?

YesNo

Do you have confirmed spine fractures on imaging?

YesNo

Do you have severe arm pain?

YesNo

Is your arm pain more severe than your neck pain?

YesNo

Do you have numbness, pins and needles or tingling in the shoulder, arm or hand?

YesNo

Do you have severe weakness in your arms or hands?

YesNo

Do you have difficulty using BOTH of your arms or hands?

YesNo

Do you have difficulty pushing, pulling or lifting objects with one or more arms?

YesNo

Do you have difficulty gripping objects with one or more hands?

YesNo

Is your pain the result of a car accident, fall or crush injury?

YesNo

Was an ambulance called?

YesNo

Did you present to the emergency room within 48 hours of your accident?

YesNo

Do you have confirmed spine fractures on imaging?

YesNo

Do you have severe weakness in BOTH legs?

YesNo

Do you have trouble standing or walking more than a few steps unaided because of weakness?

YesNo

Do you have severe numbness or pins and needles in your groin or down both legs?

YesNo

Have you developed inability to urinate or loss of control of your bladder?

YesNo

Have you noticed any weakness in ONE foot?

YesNo

Have you noticed that your foot drags, flops or catches when you walk?

YesNo

Do you have difficulty standing on your heels or toes due to weakness?

YesNo

Do you have pins and needles, tingling or numbness in your foot?

YesNo

Do you have severe pain in ONE leg?

YesNo

Is your leg pain more severe than your back pain?

YesNo

Does the pain run down the back or side of your leg?

YesNo

Does the pain go past your knee?

YesNo

Do you get pain or heaviness in your legs when you walk?

YesNo

How long have you had the pain?

less than 6 weeksbetween 6 and 12 weeksmore than 12 weeks

Are you taking any pain medication?

YesNo

How effective is this medication in relieving your pain?

Complete relief of painPartial relief of painVery little relief of painNo effect on pain

Have you had any previous scans related to your condition?

MRICTXrayNo

How will you be claiming your BackSpace visit?

Private health insuranceSelf-fundedWorkCoverDVA

Neck

Arm

Back

Leg

Duration

Severity

Medication

Imaging

Financial