First Name *

Last Name *

Email *

Phone *

1. What is the level of joint pain/discomfort you are experiencing? (10 being the most severe) *

0–2 (Minimal)

3–4 (Mild)

5–6 (Moderate)

7–8 (Severe)

9–10 (Very Severe)

2. Where is the source of your pain/discomfort? (Check All That Apply) *

Knee(s)

Hip(s)

Shoulder(s)

Elbow(s)

Wrist(s)

Ankle(s)

Back

Neck

Multiple joints

3. What type of joint pain/discomfort are you experiencing? (Check All That Apply) *

Stiffness

Aching or soreness

Sharp pain with movement

Swelling or inflammation

Grinding, popping, or clicking

Limited range of motion

Weakness or instability

4. What type of doctors have you seen for your pain you are experiencing? (Check All That Apply) *

Primary care physician

Neurologist

Pain management specialist

Orthopedic doctor

Chiropractor

Physical therapist

I have not seen a doctor yet

5. What medications or treatments are you receiving for the pain you are experiencing? (Check All That Apply) *

Prescription medications

Over-the-counter pain relievers

Steroid injections

Nerve blocks

Supplements or vitamins

Physical therapy

Chiropractic care

None

6. How did the pain/discomfort begin? (Check All That Apply) *

Gradually over time

After an injury

After surgery

I'm not sure

7. How often do you experience this joint pain? *

Occasionally

Daily

Constantly

It's getting worse over time

8. How does this joint pain affect your daily life? (Check All That Apply) *

Difficulty walking or standing

Trouble exercising or being active

Pain when sitting or sleeping

Avoiding activities you enjoy

Fear of making it worse

9. Have you had any surgeries or injections related to your joint pain or prior joint conditions? *

Yes

No

10. Do you have any additional information about your joint pain or questions about treatment options you’d like us to know?