What is your gender? *

Male

Female

Do you have any form of active cancer that you are currently receiving chemotherapy or radiation to treat? *

Yes

Have you suffered a recent acute injury to a bone, muscle, joint, tendon, ligament, or skin? *

Yes

What did you injure? *

Injury Type

Bone
Muscle
Joint
Tendon
Ligament
Skin
Unsure
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Have you received treatment for this injury? *

Yes

Please give a brief description of the treatment you've received: *

Do you suffer from chronic injury? *

Yes

Give a brief description of the injury: *

Do you suffer from any inflammation or inflammation related pain? *

Yes

How long have you been dealing with this inflammation? *

6 months-1 year
1-2 years
2+ years
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Last Name

Date of birth

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