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Dedication of the McAfee-Brantigan UMSJ Medical Library
University of Maryland
St. Joseph Medical Center
O'Dea Medical Arts Building
7505 Osler Drive, Suite 104
Towson, Maryland 21204
Telephone: 410-337-8888  / 
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Evaluation Form  
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We will respond as quickly as possible. In the meantime, if you have an urgent need to speak with us, please call us at: (410) 337.8888. Thank you for your interest!
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Name: Date:
Home Phone: Daytime Phone:
Age: Email Address:
Name of Health Insurance:
Referring Physician:
BACK PROBLEM (Check all applicable boxes)
Back Pain: Yes No  
Leg Pain: Yes No  
Buttock Pain: Yes No  
Numbness: Yes No Leg Foot
Weakness: Yes No        
NECK PROBLEM (Check all applicable boxes)
Neck Pain: Yes No  
Arm Pain: Yes No  
Numbness or Tingling: Yes No
  Shoulder Arm Hand
Have you had: X-Rays MRI CAT Scan Discogram
What were the results?
Please state the diagnosis
if available.
Have you had previous surgery? Yes No
Additional Comments:
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