First Name
*
Last Name
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Where Does It Hurt?
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Neck
Shoulder
Back
Hip
Knee
Ankle/Foot
Elbow
Wrist
Hand
Injury From Sport/Exercise
Headaches/Migraines
Not Sure Where It’s Coming From
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What Does It Stop You From Doing?
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How Long Have You Suffered or Worried?
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Haven’t - Looking For Prevention
A Few Days
1-2 Weeks
2-4 Weeks
1-3 Months
Long Enough
Too Long (Years)
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On a scale of 1-10, how much is your pain affecting your daily life
1
2
3
4
5
6
7
8
9
10
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Have you tried any treatments before? (Check all that apply)
Chiropractic
Physical Therapy
Injections
Surgery
Medication
Other
What Is Your Main Goal?
*
Ease Pain
Ease Stiffness/Tightness
Get Active
Stay Active
Avoid Painkillers/Injections/Surgery
Find Out What's Wrong
Stay Healthy & Get Fixed BEFORE Pain Gets Worse
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Phone
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Email
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