Your Name
How old are you?
Less than 20 years
20-29 years
30-39 years
40-49 years
50-59 years
60-69 years
More than 70 years
Male or Female
Male
Female
When did you first herniate your disc?
Leg Pain (1 is no pain and 10 is max pain)
1
2
3
4
5
6
7
8
9
10
Back pain (1 is no pain and 10 is max pain)
1
2
3
4
5
6
7
8
9
10
Are you working?
Same job as before.
I've taken less demanding work.
I can't work.
Retired.
Have you done physical therapy?
Yes, it helped me.
Yes, but it didn't help.
No.
Pain medication?
No- I don't take any pain medication.
I occasionally take over the counter pain medication.
I often take over the counter pain medication.
I occasionally take perscription pain medication.
I often take perscription pain medication.
How many steroid injections have you had?
1
2
3
4
5 or more.
What about surgery?
I would try ozone before surgery?
I am ready for surgery
I already had surgery
What type of surgery has your doctor discussed with you?
We haven't discussed surgery
Discectomy
Fusion
Disc Replacement
I don't know
Would you enroll in a study where you might get a placebo injection?
Yes
No
Maybe
Can we contact you with study information?
Yes
No
Your zip code:
Your email address:
