Which Statement best describes your current situation: *

I'm in pain, but I’m not sure what is causing it

I know what’s causing my pain, but I’m not sure how to relieve it

I’m Interested in a specific treatment, but I’m not sure if I qualify

I have a diagnosis, but would like another opinion

Where area/s are you experiencing the pain? (Choose all that apply) *

Neck

Middle Back

Lower Back

Shoulder

Elbow

Hand & Wrist

Head

Hip

Knee

Leg

Foot & Ankle

Describe Your Symptoms. *

How long have you been experiencing pain *

Less Than 1 Month

1-3 months

3-6 months

6-12 months

Over 1 year

How intense is your pain, from 0-10 (1 0being the worst)?

Have you tried any previous treatment with any of the following specialist? (Check all that apply) *

Chiropractor

Physical Therapy

Occupational Therapy

Acupuncture

Pain Management

Orthopedist

Neurologist

None

You have provided us with valuable information on how to assess your pain.

We appreciate you taking the time to complete this assessment and look forward to providing you with the results you are searching for!

When is the best time for our team to reach you? *

9am-11am

12pm-3pm

4pm-6pm

Full Name *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the NJ Sports Spine and Wellness.

Stay in the loop with free informational emails about exercise, stretches, new technology & machines, community events and so much more that NJ Sports Spine and Wellness offers by adding your email below!

We look forward to serving you.

Email *