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Where is the source of your pain? Choose all options that apply.
Neck
Back
Knee
Shoulder
Arms
Legs
Headache
Other
On a scale of 1-10, one being hardly any pain and ten being unbearable, how would you rate your pain?
1
2
3
4
5
6
7
8
9
10
How committed are you to fixing your pain TODAY?
Very committed
Very committed
Somewhat committed
Neutral
Not ready to commit yet
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