Low Back Pain and Degenerative Disc Disease Clinical Trial
Thank you for your interest in participating in our low back pain clinical trial at Source Healthcare in Santa Monica. Please fill out the questionnaire below to the best of your knowledge, and we will contact you if you qualify for further screening.

If you have any questions, you can direct them to the research team:
(310)574-2777 ext. 8007 or ext. 8006
Research@sourcehealthcare.com

Source Healthcare
2801 Wilshire Blvd, Suite A
Santa Monica, Blvd CA 90403
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Name (first and last) *
Email Address *
Phone Number *
Date of Birth *
MM
/
DD
/
YYYY
For BMI requirements, what is your height? *
For BMI requirements, what is your weight? *
How long have you been experiencing low back pain? *
Please rate your average pain in your low back on a scale of 0 to 10, with 0 being no pain and 10 being absolute worst pain imaginable. *
What movements reproduce the low back pain? *
Required
Have you had an epidural steroid injection in the last 3 months? *
To your knowledge, do you have a history of any of the following conditions? *
Required
If you marked anything on the question above, please elaborate on your condition(s) and how long ago you were clinically diagnosed. *
Do you have any significant radiculopathy or sciatic pain in your leg(s)? If so, is it worse or better than your back pain? *
Have you had any of the following procedures? *
Required
If yes to the previous question, how long ago did you have the procedure and to what level(s) or disc(s)? If no, write N/A. *
Are you currently receiving or have received conservative care in the past? Please elaborate. This includes physical therapy, acupuncture, chiropractor, etc. If no, write N/A. *
Are you currently using any of the following treatments? *
Required
What pain medication are you taking, if any? Are you on a stable regimen with this medication? *
When was your most recent lumbar MRI done? Do you have access to the images? *
Do you have any active implantable devices (i.e., cardiac pacemaker, spinal cord stimulator, intrathecal pump)? *
Do you have any allergies? If yes, what are they? *
Have you participated in another clinical trial within the last 120 days? *
Are you presently receiving compensation according to the Workers' Compensation Act or are involved in personal injury litigation due to a back-related injury? *
Are you pregnant/nursing or planning on being pregnant within the next year? *
Is there anything else you would like to let us know about your current state of health, medical history, or back condition that was not covered above? If yes, please provide a brief explanation. *
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