Where are you experiencing pain/discomfort?

What is the problem you are experiencing?

• Knee/Joint Pain
• Back Pain
• Neuropathy
• Neck/Shoulder Pain
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On a scale of 1-10, one being hardly any pain and ten being unbearable, how would you rate your pain?

1

2

3

4

5

6

7

8

9

10

Describe your Pain/ Discomfort.

Sharp

Aching

Burning

Stiffening

Numbness & Tingling

Something Else

How long have you had this problem? *

0-3 Months

3-12 Months

1-3 Years

Over 3 Years

What type of doctors have you seen? Choose all options that apply.

Chiropractor

Pain Management

Neurologist

Orthopaedic Surgeon

General/Family Doctor

Other

None

What have you tried in the past that has not corrected your problem?

Aspirin, Tylenol or Advil

Steroid Injections

Prescription Pain

Physical Therapy

Surgery

Other

What aspects of your life are being negatively impacted? *

Marriage/Relationships

Ability to Exercise

Work

Mood

Sleep

On a scale of 0 - 5 how important is it for you to get this problem corrected?

1

2

3

4

5

Are you interested in continuing into a paid exam following the complimentary consultation?

YES

NO

First Name *

Last Name *

Phone *

Email *

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