Take our Knee Pain Quiz
Do you have Joint Pain?
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Yes
No
Where is the source of your pain? Choose all options that apply.
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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?
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Yes, on both knees
Yes, but only on one knee
No
Have you taken Medication to help with your pain?
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Yes
No
Is your pain affecting your daily activities?
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Yes
No
What areas of your life are affected by the pain? Choose all options that apply.
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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?
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Very committed
First Name
*
Email
*
Last Name
*
Phone
*
Please Select your Primary Insurance (If Any)
*
Please Select your Secondary Insurance (If Any)