What is your First Name?
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Phone Number
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Where is your primary pain located?
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Back Pain
Knee Pain
Hip Pain
Shoulder Pain
Head & Neck Pain
Ankle & Foot Pain
Elbow & Wrist Pain
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What is your age range?
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21 and under
22–34
35–49
50–64
65+
Are you currently a Medicare beneficiary?
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Yes
No
How long have you had this pain?
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Less than 1 month
1–6 months
6–12 months
More than 1 year
Have you tried anything to address your pain so far?
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Yes, but I’m still dealing with the problem
Yes, and it helped somewhat
No, this is my first time seeking help for it
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What's the biggest thing your pain is preventing you from doing?
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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?
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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
Why is getting out of pain so important to you?
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I want to get back to my regular workouts
I'm not as active as I used to be with my family & friends
I want to stay strong and competitive in my sport
It's affecting my life outside the gym too
How soon are you hoping to get started?
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As soon as possible
Within the next few weeks
I'm still exploring my options
I'm mainly looking for free information
Thank You! Just One More Step...
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