Vertebral Motion Analysis Screening
VMA Form Completion Date
Date of Injury
Patient Information
Full (Legal) Name
Email
*
Please use the same email that was used on previous forms
Medical History
Have You Been Diagnosed With Any Spinal-Related Conditions Or Injuries?
Yes
No
If yes, please provide details (condition, date, treatment received, etc.).
Do You Currently Have Any Pain, Discomfort, Or Limited Mobility In Your Neck Or Lower Back?
Yes
No
If yes, please describe the nature, location, and severity of the symptoms.
Do You Have A History Of Arthritis, Degenerative Disc Disease, Spinal Stenosis, Scoliosis Or Other Spinal Conditions?
Yes
No
If yes, please specify the condition(s) and any related treatment.
Have You Had Any Spinal Surgeries Or Spinal Procedures?
Yes
No
If yes, please provide details (type of surgery, date, and outcomes).
Do You Have A Family History Of Any Spinal-Related (Congenital) Conditions Or Disorders?
Yes
No
If yes, please provide details
Additional Information:
Please provide any other information about your injury or symptoms you feel is important at this time?
Form Completed By
*
I hereby certify that, to the best of my knowledge, the provided information is true and accurate. I agree to terms & conditions provided by the company.
Patient Signature
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