Where are you experiencing pain? (Choose all that apply)
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Cervical (neck) region
Thoracic (mid-spine) region
Lumbar (lower back) region
Shoulders or Arms
Hip, Buttocks, or Legs
Joints (wrists, elbows, knees, ankles, etc.)
Other
How long have you been experiencing pain?
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0 to 6 months
6 months to 1 year
More than 1 year
Are you always in pain?
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Yes, I'm in constant pain that may worsen depending on the activity I'm doing.
No, it comes and goes depending on what activity I'm doing or what position I'm in.
Describe any pain-related symptoms (Choose all that apply)
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Stabbing, shooting, or radiating pain
Tenderness, throbbing, or dull aching
Numbness, tingling, or pins-and-needles sensations
Burning or stinging
Stiffness or reduced range of motion
Localized swelling or global inflammation
Muscular cramps or spasms
Progressive weakness
Lack of balance or coordination
Difficulty walking, bending, sitting, or rotating the spine
"Crunching" or grinding sensations in joints
Other
How did your pain begin?
*
Not sure
Lifting something heavy
Vehicle crash or accident
Slip or fall
Traumatic Injury
Other
Which of the following treatments have you tried?
*
Self-care (rest, over-the-counter medications, ice & heat application, etc.)
Alternative Therapy (Yoga, Acupuncture, Massage Therapy)
Chiropractic Care
Physical Therapy
Pain Management (prescription strength pain medication, joint or spine injections, etc.)
Surgical Intervention
Other
Have you received diagnostic imaging for this concern?
X-ray
MRI
CT Scan
SPECT Scan
Ultrasound
EMG/ NCV Studies
No, I haven’t
If you have received an MRI, how long ago was it?
0 to 6 months
6 months to 1 year
1 to 2 years
2 years or more
What type of insurance do you have?
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Who is your primary insurance carrier?
*
Do you have out-of-network benefits?
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Yes
No
Not Sure
First Name
Last Name
Phone
*
Email
*
Location Preference
Best Time to Call
Anything else you would like for us to know?
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