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Chronic Pain Syndrome Ratings

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Complete the form below.
When you are finished, click the Submit button
at the end of this form
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Type of Accident or Injury.

Date of Accident or Injury.

What Type of Services Do You Need?
Check ALL that apply.
If you do not know, Click Here

Spinal Impairment Rating
Convert Whole Person Impairment to Regional Spine Impairment
Functional Capacity Assessment
Spinal Disability Evaluation
Chronic Pain Syndrome Rating
Independent Medical Exam (IME) Second Opinion
Work Restriction Documentation
Lost Pre-Injury Capacity Documentation
Scoliosis Impairment Rating
Regional Scoliosis Impairment Rating
Case Review - File Review
I Don't Know
Other

Where is your pain?
Please check the following boxes if they apply.
You can choose more than one box.
Neck Mid-Back Low Back Arms and Legs

Have you been to a doctor for
this condition before?
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Did you ever have an Impairment Rating for
this accident? Yes No

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attorney for this accident? Yes No

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of the accident below.

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Contact Information

Dr. Gerald R. Lapinsky, DC, CSDE, DABDA

Postal address: P.O. Box 7644 Phoenix, AZ 85011-7644
Telephone
602-997-2273

DISCLAIMER: The information contained on this web site is not intended to alleviate, improve, maintain or cure medical and/or non-medical condition(s). This material does not constitute medical and/or legal advice. This web site is intended for informational purposes only. Consult a licensed physician for specific recommendations and treatment.

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