What is the problem you are experiencing?
*
Knee Pain
Joint Pain
Lower Back Pain
On a scale of 1-10, one being hardly any pain and ten being unbearable, how would you rate your pain?
*
1
2
3
4
5
6
7
8
9
10
Describe your Pain/ Discomfort.
*
Sharp
Aching
Burning
Stiffening
Numbness & Tingling
Something Else
How long have you had this problem? *
0-3 Months
3-12 Months
1-3 Years
Over 3 Years
What type of doctors have you seen? Choose all options that apply.
*
Chiropractor
Pain Management
Neurologist
Orthopaedic Surgeon
General/Family Doctor
Other
None
What have you tried in the past that has not corrected your problem?
*
Aspirin, Tylenol or Advil
Steroid Injections
Prescription Pain
Physical Therapy
Surgery
Other
What areas of your life are affected by the pain? Choose all options that apply.
*
Maintaining a safe environment
Communication with colleagues and/or loved ones
Breathing
Eating & drinking
Washing & dressing
Working & playing
Expressing sexuality
Sleeping
Finances
Household chores
Self worth/value
Physical well-being
Emotional health
Other
What activities are being negatively affected?
*
Walking
Sit to Stand
Kneeling
Playing Sports
Up and Down Stairs
What aspects of your life are being negatively impacted? *
Marriage/Relationships
Ability to Exercise
Work
Mood
Sleep
On a scale of 0 - 5 how important is it for you to get this problem corrected?
*
1
2
3
4
5
Is there anything else you’d like to share with us regarding your goals?
You QUALIFY for a FREE Pain Relief Consultation!! What time of day works best for you?
*
Mornings
Afternoons
Evenings
Are you interested in continuing into a paid exam following the complimentary consultation?
YES
NO
First Name
*
Last Name
*
Phone
*
Email
*
I agree to
terms & conditions
provided by the company. By providing my phone number, I agree to receive text messages from the business.