Hours

By appointment only:

9-12 and 1-5 Monday through Friday

 

Information Request Form

Please Print This Form and Then

Fill Out As Completely As Possible and Fax to 310-558-0624

Contact Information

First Name:

Last Name:

E-mail Address:

Verify E-mail Address:

Mailing Address

Street:
City:
State (if USA):
Zip:
Country (if not U.S.A):

Home Phone:

Work Phone:

Cell Phone:

Fax:

Medical Information

Age:             Sex:

Allergies:

Medications:

Please choose Male Female
Is your problem a work related injury? Yes [ ] No [ ]

Please indicate your insurance category:
PPO
HMO
Workers Comp.
Auto Insurance
Cash Pay
Insurance Company Name:
ID Number
Group Number

Describe your problem:


If your predominant pain is neck related, please check the following if you have one or more of these symptoms:

Left arm pain, numbness or weakness
Right arm pain, numbness or weakness

If your predominant pain is low back related, please check the following
if you have one or more of these symptoms and which leg is worse:

Left leg pain, numbness or weakness
Right leg pain, numbness or weakness

Please rate the percentage of back/leg pain [ ]%Back [ ]%Leg

Do you have any of the following? Please check all that apply.

Osteophytes or Spurs or Spinal Stenosis? If so, how many levels 0 1 2 3 4

If your predominant complaint is thoracic (mid back pain)

Mid back pain

Have you had spine surgery? If yes, when, where, and who was the surgeon?


Have you seen a surgeon? What was recommended?


Have you had a MRI scan? If so, what is the impression or
summary at the bottom of the scan report?
(It is very important that you let us know the the entire summary
at bottom of your scan report.)


What tests and treatment have you had?

Have you had any epidural steroid injections yet?


What questions would you like to ask Dr. Gross?


What Search Engine and words did you use to find us?
If not by a Search Engine, how did you find us?