What is the problem you are experiencing? *

Back Pain

Low Back Pain

Sciatica

Neck Pain

Knee Pain

What is your Pain/Discomfort Level on a scale of 0-10? *

No Pain 0 - 10 Worst Pain

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
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Describe your Pain/Discomfort *

May select multiple

• Constant Discomfort
• Aching
• Severe Pain
• Stiffening
• Numbness & Tingling
• Burning
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How long have you had this problem? *

0-3 months

3-12 months

1-3 years

Over 3 years

How many providers have you seen for this problem? *

None

1

2

3

More than 3

On a scale of 0 - 10 how important is it for you to get this problem corrected?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
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Is there anything else you’d like to share with us regarding your goals?

Full Name

Email *

Phone *

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