Manipulation Under Anesthesia (MUA)
Doctor Reviewed Pre-Consultation

 

Are you a good candidate for our 3 Days to Relief MUA treatment?


The first step in finding out whether manipulation under anesthesia (MUA) is something you should consider for ending your pain and increasing your range of motion is to fill out the pre-consultation form below. Once you submit the form, one of our doctors will review your answers and tell you if you’re a likely candidate. Naturally, the answers you give below are not the only information we’d need to make a medically-sound decision or recommendation. But, they do provide enough data to identify those that we believe can be truly helped by MUA. When you fill out the form, please make sure to provide a valid email address so that we can communicate with you. Or, if you prefer, please provide a phone number where we might contact you with information about your condition and MUA.

Finally, please be assured that the information you provide is private, and will not be shared with anyone outside the clinic.

  

* All questions with an asterisk are required
 

Last Name*: 

First Name*: 


 

Full Address: 

 

City: 

 

State*: 



 

Zip: 

Email*: 


 

We will email you your results – please provide valid email.

Phone: 

 

 

1. 

* Your main complaints / symptoms: Check as many as appropriate

 Low Back Pain

 Mid Back Pain

 Neck Pain

 Pain in the Legs

 Pain in Arms

 Numbness in Legs or Feet

 Failed Back Surgery

 Frozen Shoulder

 Fibromyalgia

 Recurrent Sporting Injuries

 Generalized Joint Pain

 Restricted Spinal Motion

 

2. 

When did your symptoms first develop?: 

  Month: 

  Year: 

 

 

3. 

What do you think caused them to develop?:


What activities make your symptoms worse?


What activities alleviate or reduce your symptoms?


Have your symptoms been getting progressively worse over time? Yes    No
If yes, please state time frame (e.g. “past 3 months”)  

Is this problem worse at any time of day?:    No     Morning     Midday     Evening     Other (please specify) 

 

4. 

Can you remember any events that worsened your condition or caused a “flare up”?
(E.G. You underwent a surgery, which worsened it OR you were involved in an auto accident, which created an extra symptom OR you were involved in a sporting injury):
No    Yes (describe below)

Event 1:

  

Date / range: 



Description: 
 

Event 2:

  

Date / range:

Description: 
 

Event 3:

  

Date / range:

 

Description: 

5. 

* Please list previous therapies you have tried (and the results you received from each):
Medical Pain Management


i) Epidural

Helped a lot    Helped a bit / for a while    Did not help    Made me worse

ii) Pain Meds

Helped a lot    Helped a bit / for a while    Did not help    Made me worse

iii) Surgery

Helped a lot    Helped a bit / for a while    Did not help    Made me worse

iv) Facet Blocks

Helped a lot    Helped a bit / for a while    Did not help    Made me worse

Stretching exercises  

Helped a lot    Helped a bit / for a while    Did not help    Made me worse

Massage

Helped a lot    Helped a bit / for a while    Did not help    Made me worse

Physical Therapy

Helped a lot    Helped a bit / for a while    Did not help    Made me worse

Chiropractic

Helped a lot    Helped a bit / for a while    Did not help    Made me worse

Decompression

Helped a lot    Helped a bit / for a while    Did not help    Made me worse

Traction

Helped a lot    Helped a bit / for a while    Did not help    Made me worse

Acupuncture

Helped a lot    Helped a bit / for a while    Did not help    Made me worse

 

6. 

Which of these invasive procedures have you had if any?:

 IDET

 Discectomy

 Laminectomy (Lumbar)

 Laminectomy (Cervical)

 Lumbar Spinal Fusion

 Cervical Spinal

 Fusion

 Nucleoplasty

 Radiofrequency Ablation

 Disc Replacement

 Spinal Cord Stimulator Implantation

 Morphine Pump

 

7. 

Have you lost full use / range of motion of any of the joints of your body? (incl. neck and back):
No    Yes (explain):

 

8. 

Have you ever had failed back surgery? (back surgery that resulted in more / a different kind of pain):
No    Yes (explain: When / how many etc):

 

9. 

* What are your reasons for considering the MUA procedure?
(Please mark each that applies to you)

 I want to avoid surgery

 I want to avoid long-term medication use

 Other therapies didn’t work

 Other therapies didn’t work enough

 Pain is preventing me from working

 Pain is interfering with my job

 I have unsightly muscle contracture

 Meds / drugs no longer work for me

 Surgery has made me worse

 Therapists have discharged me

 My doctor says he has done all he can do

 Pain interrupts my sleep

 I have a “frozen” joint

 My symptoms keep coming back

 Pain interferes in my social life

 

 Other:

 

10.

* Do you have (or have you been told that you have) any of the following?
(READ THIS LIST CAREFULLY)


 Have / Had Cancer (which?)
 Rheumatoid arthritis

 Syphilis

 Tuberculosis (TB)

 Psoriatic arthritis

 Gonorrhea

 Recent bone fractures

 Active Gout

 Tumor of spinal cord

 Old compression fractures of the spine

 Diabetic neuropathy

 Bone infection

 Aneurysm

 History of cardiovascular disease

 History of stroke

 None of these

Explanation or question: