Full Name *

Email *

Phone *

Q1. Where do you experience pain most often? *

Neck

Shoulders

Jaw / TMJ

Back

Hip

Knee

Foot/ankle

Q2. How long have you been dealing with this pain? *

Less than 30 days

More than 30 days

Q3. How often does your pain interfere with your daily life? *

Not at all

A little bit

Sometimes

Quite a lot

Very much

Q4.Which treatments have you already tried? *

Physical therapy

Massage Therapy

Chiropractic Care

Stretching or Mobility Exercises

Medication

Nothing Yet

(Select all that apply.)

Q5.If you've tried treatment before, what was the result? *

It completely solved my problem.

It helped some, but didn’t fix my problem.

It barely helped at all.

No improvement.

Have not tried any treatment yet

Q6. What has your pain prevented you from doing? *

Working comfortably

Exercising

Sleeping well

Playing with my kids or family

Enjoying hobbies

Living without constantly thinking about my pain

Q7. If your problem was solved with physical therapy, how meaningful would that be to you and your life? *

Minimal to no effect

Somewhat meaningful

Very meaningful

It would change my life completely

Q8. What would improving your pain allow you to do? *

Complete my work more effectively

Get back to exercising

Sleep better

Spend more quality time with family

Feel like myself again

Q9. On a scale of 1–10, how committed are you to finally solving this problem? *

1 = Just Curious

10 = I'm Ready to Fix It ASAP

Q10. If we could identify the real cause of your pain and create a personalized treatment plan, would you like to learn more? *

Yes

Maybe

I just wanted my results