Do you have a diagnosis of scoliosis?*YesNo If Yes, How big is your curve?Please enter a number from 1 to 100.degrees Do you have uneven hips?YesNo How uneven?MildModerateSevere Do you have uneven shoulders?YesNo How uneven?MildModerateSevere Do you have a rib prominence (bump on your back)?YesNo How big is the rib prominence?MildModerateSevere Have you experienced any height loss over the last several years?YesNo If so, how many inches?1-22-3Greater than 3 Inches Do you experience any of the following sensations? Numbness Tingling Burning Sharp Throbbing Quick Jolts Do you have back pain?YesNo Where is the pain?Over the bumpLower BackOther How severe would you rate the pain? Do you have shooting leg pain or sciatica?YesNo Have you had this pain for more than 6 months?YesNo How severe would you rate the pain? Have you undergone any of the following? X-Ray Bending X-Ray Left-Hand X-Ray MRI Nerve Conduction Study Other Contact InfoName*Email* Phone*Interested in scheduling an in person consultation?*YesNoComments This iframe contains the logic required to handle Ajax powered Gravity Forms.