Where is your pain located? *

Knees

Hips / pelvis

Shoulders

Back

None of the above

How would you rate your pain or discomfort today? (On a scale of 1–5) *

1 – Mild

2 – Moderate

3 – Uncomfortable

4 – Severe

5 – Very severe

Please describe the issue or pain you're experiencing. * *

How long have you been dealing with this issue? *

Less than 6 months

6–12 months

1–3 years

Over 3 years

Do you feel the pain spreading into other areas when you move? *

Yes

What symptoms are you currently experiencing? (Select all that apply) *

Pain when moving, walking, bending, or lifting

Swelling or stiffness

Numbness or tingling

Joint instability or weakness

Shooting pain during movement

Clicking, popping, or joint locking

Difficulty standing, sitting, or climbing stairs

None of these

Have you had any joint or mobility-related treatment before? *

Yes

Do you have any injuries, joint issues, or movement limitations? *

Yes

Have you been diagnosed with any of the following? (Select all that apply) *

Joint inflammation

Arthritis

Mobility restrictions

Chronic joint pain

None of the above

Are you actively looking for treatment or just exploring? *

Actively looking

Just exploring

Not sure

If you qualify, are you ready to start treatment? *

Yes, I’m ready to get started

Not yet, just researching

What days/times are you typically available for an appointment? *

What is your age/weight? *

Address

Street Address *

City *

State *

Country *

Country

Postal Code *

First Name *

Last Name *

Email *

Phone *

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