What’s your main reason for completing this form today?

I’m curious about my symptoms

I’m unsure who to see

I want a second opinion

I want treatment and a plan

How would you describe your current discomfort or injury?

Mild discomfort

Moderate pain, affecting daily activities

Severe pain, limiting mobility

Disturbing, wakes me up at night

How Long Have You Been In Pain For?

A Few Days

A Few Weeks

Over A Month

At Least A Year

Does this discomfort prevent you from engaging in activities you enjoy?

No, I can still do these

Sometimes, it's just certain movements

Yes, all the time

Brief History of Pain / Injury

Have you tried any other treatments or exercises to manage the pain?

No, not yet

Medicated Pain Relief

Yes, but didn't do anything

Waiting List for physio

Yes, I am seeing some improvement

Yes, I go to another Therapist too

Would you be interested in speaking with one of our Lincs Injury Team to assess your pain and create a personalised plan?

Yes, I’d like to book a consultation

Unsure, I’d like to take advantage of the free consultation first

Not ready to book, but I’d like some helpful resources for now

Email *

Full Name

Phone

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