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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  
   
For your convenience, we offer this online Evaluation Form. Be sure to provide a daytime telephone number &/or email address so that we can reach you. Please refer to our » Privacy Policy for additional information about security measures and our policy regarding your privacy.
   
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!
   
» Click for a "Print & Fax" version of this form.
 
* = Required information to complete request.
 
 
* 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:
 
Please email or fax additional medical reports if available.  Our fax number and email address are provided on "Contact Us".
 
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Read more about Dr. Paul McAfee by visiting "About Us" or click on any of our other helpful web pages. Please feel free to get in touch with us!  Visit "Contact Us" for details.
 
 
 

Offices in
Towson
MD 21204
 
       
 
For Location & Contact...
 

For driving directions or contact information visit "Contact Us".
 
 
   
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