Sign Up — Disc Centers of America

Name:

Street:

City:

State:

ZIP Code:

Telephone Number:

Email:

Please Check All That Apply:

Primary Concern - Select One:

How Long Has This Been Going On:

0-6 months

6 months to one year

1 to 5 years

5+ years

If You Could Discover The Root Of Your Issue Would You Want to Correct It:

Yes

No

Doctors Area:

Mainly White Ideal Muscle and Nerve

Majority Green, Mild Muscle Spasm

Majority Blue, Moderate Muscle Spasm

Red areas indicate Severe Muscle spasm and possible nerve dysfuntion

Black areas found, these are off of our charts and can indicate extreme muscle spasms

Major Asymmetries which are a great predictor of injury

DCOA:

Yes

No

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