Patient Coverage Form

Date

Date of Injury

Full (Legal) Name

Date of birth

Age

Gender

Best Email Address *

Best Contact Telephone Number *

Address

State

City

Postal code

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.

Have You Been Involved In A Motor Vehicle Crash, Fall, Or Other Injury To Your Neck Or Lower Back?

Yes

No

If yes, please provide details (date, cause, and any immediate symptoms experienced).

Are You Currently Receiving Treatment For Spine-Related Symptoms/Pain?

Yes

No

If yes, please provide details (type, duration, and effectiveness of treatment).

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).

Frequency Of Symptoms

Occasional (1-25% waking hours)

Intermittent (26-50% waking hours)

Frequent (51-75% waking hours)

Constant (76-100% waking hours)

Severity

Minimal

Slight - Moderate

Severe

Frequency Of Symptoms

Occasional (1-25% waking hours)

Intermittent (26-50% waking hours)

Frequent (51-75% waking hours)

Constant (76-100% waking hours)

Severity

Minimal

Slight - Moderate

Severe

Frequency Of Symptoms

Occasional (1-25% waking hours)

Intermittent (26-50% waking hours)

Frequent (51-75% waking hours)

Constant (76-100% waking hours)

Severity

Minimal

Slight - Moderate

Severe

Frequency Of Symptoms

Occasional (1-25% waking hours)

Intermittent (26-50% waking hours)

Frequent (51-75% waking hours)

Constant (76-100% waking hours)

Severity

Minimal

Slight - Moderate

Severe

Frequency Of Symptoms

Occasional (1-25% waking hours)

Intermittent (26-50% waking hours)

Frequent (51-75% waking hours)

Constant (76-100% waking hours)

Severity

Minimal

Slight - Moderate

Severe

Frequency Of Symptoms

Occasional (1-25% waking hours)

Intermittent (26-50% waking hours)

Frequent (51-75% waking hours)

Constant (76-100% waking hours)

Severity

Minimal

Slight - Moderate

Severe

Frequency of Symptoms

Occasional (1-25% waking hours)

Intermittent (26-50% waking hours)

Frequent (51-75% waking hours)

Constant (76-100% waking hours)

Severity

Minimal

Slight - Moderate

Severe

Frequency Of Symptoms

Occasional (1-25% waking hours)

Intermittent (26-50% waking hours)

Frequent (51-75% waking hours)

Constant (76-100% waking hours)

Severity

Minimal

Slight - Moderate

Severe

Frequency Of Symptoms

Occasional (1-25% waking hours)

Intermittent (26-50% waking hours)

Frequent (51-75% waking hours)

Constant (76-100% waking hours)

Severity

Minimal

Slight - Moderate

Severe

Frequency Of Symptoms

Occasional (1-25% waking hours)

Intermittent (26-50% waking hours)

Frequent (51-75% waking hours)

Constant (76-100% waking hours)

Severity

Minimal

Slight - Moderate

Severe

Any Specific Position(S) That Increase Or Decrease Your Symptoms?

Yes

No

If yes, please provide details:

Do You Have A Family History Of Any Spinal-Related (Congenital) Conditions Or Disorders?

Yes

No

If yes, please provide details

Provider Signature

Clear

Patient Signature

Clear

Patient Coverage Form

Complete this form for your VMA Scan