Take our Knee Pain Quiz
Do you have Joint Pain?
*
Yes
No
Where is the source of your pain? Choose all options that apply.
*
Knee
Shoulder
Wrist
Hand
Foot
Other
On a scale of 1-10, one being hardly any pain and ten being excruciating, how would you rate your pain?
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1
2
3
4
5
6
7
8
9
10
Have you been told that you need knee replacement surgery?
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Yes
No
Have you had knee replacement surgery?
*
Yes, on both knees
Yes, but only on one knee
No
Have you taken Medication to help with your pain?
*
Yes
No
Is your pain affecting your daily activities?
*
Yes
No
What areas of your life are affected by the pain? Choose all options that apply.
*
Maintaining a safe environment
Communication
Breathing
Eating & drinking
Washing & dressing
Mobilization
Working & playing
Expressing sexuality
Sleeping
Daily parenting
Finances
Household chores
Self worth/value
Physical well-being
Emotional health
Other
How committed are you to fixing your pain TODAY?
*
Very committed
Very committed
Somewhat committed
Neutral
Not ready to commit yet
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First Name
*
Email
*
Last Name
*
Phone
*
Please Select your Primary Insurance (If Any)
*
Medicare
Blue Cross/Blue Shield
United Healthcare
Cigna
Aetna
Humana
Medicaid
UMR
Wellcare
Ambetter
Cash/Out of pocket
Blue Cross/Blue Shield - MA
United Healthcare - MA
Cigna - MA
Aetna - MA
Humana - MA
UMR - MA
Wellcare - MA
Ambetter - MA
Other
Blue Open Access POS
Blue Pathway Guided Access HMO
Champva
CareSource-GA
Blue Cross Blue Shield Open Access POS
Allied Benefit Systems
Oscar
Blue Cross Blue Shield Federal
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Please Select your Secondary Insurance (If Any)
No secondary
Medicare
Humana
Cigna
United Healthcare
Aetna
Medicaid
Wellcare
Ambetter
Tricare Prime East Region
Other
BCBS (Blue Cross Blue Shields) of Alabama
Blue California
Blue Cross Blue Shields
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