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
Where is the source of your pain? Choose all options that apply.
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Neck
Back
Knee
Shoulder
Arms
Legs
Headache
Other
What type of doctors have you seen? Choose all options that apply.
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Chiropractor
Pain Management
Neurologist
Orthopaedic Surgeon
General/Family Doctor
Other
None
How did the pain begin? Choose all options that apply.
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Accident at home
Vehicle accident
Accident at work/work related
It just began
After surgery
Came on gradually
Sports related
Other
Have you had any surgeries to your existing pain or any other pain condition?
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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
Very committed
Somewhat committed
Neutral
Not ready to commit yet
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PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: I will NOT miss my appointment once it is scheduled and confirmed because I respect your time and I understand it's not fair to others who would schedule in my place if I don't show up. I understand I forfeit my scheduling fee if I do not show.
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Yes
No
PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: I understand that the office is located at - 1355 Oakfield Dr, Brandon FL, 33511.
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Yes
No
First Name
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Last Name
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Phone
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Email
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Zip Code
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