First Name

Last Name

Mobile Phone

Email

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Date of birth

Format as MM/DD/YYYY or 03/15/1985

Gender

Female

Male

Decline to specify

Address

Street Address

City

State

Country

Country

Postal code

Primary area of concern? *

Low Back

Neck

Shoulder

Elbow

Knee

Hip

Hand/Wrist

Foot/Ankle

Laterality (Which side?)

Right

Left

Both

Not applicable

In your own words, please briefly describe your main issue or complaint:

CURRENT pain level

BEST pain level

WORST pain level

HOW did your current problem start?

HOW LONG have you experienced the problem?

Following a specific date of injury

Weeks

Months

Years

Not sure or unable to remember

SPECIFIC DATE of injury?

Format as MM/DD/YYYY or 03/15/2025

How many WEEKS?

How many MONTHS?

How many YEARS?

Describe the TIMING of your symptoms:

Constant

Comes and goes

Intermittent

Unpredictable with no pattern

Describe the FREQUENCY of your symptoms or how often they occur:

Hourly

Few times a day

Daily

Few times a week

Weekly

Few times a month

Monthly

Rarely, less than monthly

Unpredictable with no pattern

Over the last WEEK, how have your symptoms progressed?

Getting better in the last week

Staying the same in the last week

Getting worse in the last week

Over the last MONTH, how have your symptoms progressed?

Getting better in the last month

Staying the same in the last month

Getting worse in the last month

How long can you SIT in one place without the need to move?

More than one hour

45 - 60 minutes

30 - 45 minutes

20 - 30 minutes

10 - 20 minutes

5 - 10 minutes

Less than 5 minutes

How long can you STAND without the need to move?

More than one hour

45 - 60 minutes

30 - 45 minutes

20 - 30 minutes

10 - 20 minutes

5 - 10 minutes

Less than 5 minutes

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