What is your First Name?
*
Phone Number
*
Where is your primary pain located?
*
Back Pain
Knee Pain
Hip Pain
Shoulder Pain
Head & Neck Pain
Ankle & Foot Pain
Elbow & Wrist Pain
common.other_option
What is your age range?
*
21 and under
22–34
35–49
50–64
65+
Will a parent or guardian be involved in your decision to get care?
*
Yes, they’re aware and will be involved in the process
Yes, but I’ll mostly be handling this on my own
No, I’ll be handling this on my own
Are you currently a Medicare beneficiary?
*
Yes
No
How long have you had this pain?
*
Less than 1 month
1–6 months
6–12 months
More than 1 year
Which best describes what you're dealing with?
*
This is a recent flare-up of a problem I've dealt with before
This is related to a significant injury or recent surgery
This is a new issue that's persisting, getting worse, or affecting what I can do
This is a new, relatively minor issue that I'm just starting to look into
Have you tried anything to address your pain so far?
*
Yes, but I’m still dealing with the problem
Yes, and it helped somewhat
No, this is my first time seeking help for it
common.other_option
Which best describes why you're looking for help now?
*
I’ve been dealing with this for a while and I’m ready to finally address it
It’s starting to affect my workouts, sport, or everyday activities
I want to address it before it becomes a bigger problem
It’s a relatively minor issue and I’m mostly just seeing what my options are
How much is your pain affecting the things you want to do?
*
It’s keeping me from working out, playing my sport, or doing activities I enjoy
I can still do most things, but I’m having to modify or push through the pain
It’s affecting my everyday life, not just physical activity
It isn’t limiting me much right now, but I want to address it before it gets worse
Which best describes what you're looking for from Next Level?
*
A traditional physical therapy approach (basic exercises and stretches)
A deeper-rooted solution that connects the dots
An expert who understands the unique needs of athletes and gym-goers
I'm not sure what I'm looking for, but I'm open to finding the right solution
How soon are you hoping to get started?
*
As soon as possible
Within the next few weeks
I'm still exploring my options
I'm mainly looking for free information
Which best describes your familiarity with Next Level before filling this out?
*
I’ve known about Next Level for a while and have been considering coming in
I recently found Next Level and took some time to learn more about you
I’ve seen Next Level before, but haven’t really looked into you
I just came across Next Level and this is my first time learning about you
We work best with athletes and gym-goers who want to understand the deeper root cause of their pain, get back to the activities they love, and are looking for individualized one-on-one care rather than just a temporary fix. Does that sound like what you’re looking for?
*
Yes, that sounds like what I’m looking for
No, that’s not really what I’m looking for
Thank You! Just One More Step...
Please confirm your email. This helps our team keep your information up to date as we review your answers.
*