Spine Digital Health Assessment
This brief assessment will help you assess your spine health and determine if a specialized spine evaluation may be a good option for you.
Start Your Assessment
 
Please Agree to the Terms of Use *

You are voluntarily choosing to provide information to Summit Orthopedics, Ltd (“Summit”) through this web page. Providing your contact information or completing the Spinal Risk Assessment (SRA) does not make you a patient of Summit. Summit is only providing general information not medical advice. To become a patient, you will need to schedule an appointment and receive health care services from Summit. The SRA is not and does not generally become part of a patient record at Summit. If you provide your contact information in the SRA, complete the SRA or make an appointment through this web page, Summit will use this information to contact you to schedule an appointment or provide information to you about its health care services. Information that you provide on this web page may not be protected by the federal HIPAA privacy law or other privacy laws.

If you think you may have a medical emergency, please call your doctor or 911 immediately.
     
 
Let's get started! What is your first name? *

 
Thank you, {{answer_PV98J7udIcHX}}.

What is your last name? *

 
What is your gender? *


 
What is your birthday? *

 
Thank you, {{answer_PV98J7udIcHX}}! I am now going to ask you some questions about your back health history.

Your answers will be treated with the utmost privacy.
 
About Your Back Health

 
Have you pursued treatment, evaluation or consultation from a medical doctor for your back pain or discomfort? *


 
How long has the pain from your back persisted (not stopped)? *


 
Are you a current cigarette smoker? *


 
When you stopped smoking, did your back pain decrease or become less frequent? *


 
During the past month, how would you describe the pain you usually have from your back? *


 
During the past month, have you had trouble walking because of your back? *


 
During the past month, have you been unable to bathe, dress, or complete daily activities without help because of your back? *


 
During the past month, have you had any trouble getting in and out of the car or other transportation because of your back? *


 
During the past month have you been able to sit for an extended period of time or rise from a chair comfortably? *


 
During the past month, have you been bothered at night by pain from your back? *


 
Thank you, {{answer_PV98J7udIcHX}}! I am now going to ask you some questions about your pain history.

Your answers will be treated with the utmost privacy.
 
About Your Pain

 
Has the use of pain management medication (prescription or over the counter) or topical treatments (cream, gels, etc.) decreased the pain intensity or duration? *


 
Have you previously tried other treatment options to manage your pain and discomfort? *


 
If you have attempted alternative treatment options, how effective were they? *


 
Have you experienced any of these common problems? *


 
Have you been diagnosed with any of the following? *


 
Please provide your phone number. *

 
Please provide your zip code. *

Thanks, {{answer_PV98J7udIcHX}}!
You have completed the spine health digital health assessment.

Click the button to view your results.
View Results
Thanks, {{answer_PV98J7udIcHX}}!
You have completed the spine health digital health assessment.

Click the button below to view your results.
View Results
Thanks, {{answer_PV98J7udIcHX}}!
You have completed the spine health digital health assessment.

Click the button below to view your results.
View Results