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Laser Therapy Questionnaire
1
Name
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First Name
Last Name
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2
Email
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example@example.com
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3
Phone Number
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Please enter a valid phone number.
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4
Where is your primary pain located?
*
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Head/Neck
Middle Back
Lower Back/Hips
Wrist/Elbow/Hand
Knee/Ankle
Foot
Other
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5
How long have you been experiencing your symptoms?
*
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Less than 6 months
6 months to 1 year
More than 1 year
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6
How often do you experience your symptoms?
*
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25% of the day orless
50% of the day
75% of the day
My symptoms areconstant
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7
Is your pain due to a recent accident or injury?
*
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YES
NO
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8
Are you currently taking NSAIDS or Steroids?
*
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YES
NO
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9
Are you currently pregnant?
*
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YES
NO
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10
Are you currently diagnosed with a malignancy (cancer)?
*
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YES
NO
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11
Are you interested in learning how laser therapy helps chronic and acute muscle pain and injuries?
*
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YES
NO
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12
Please verify that you are human
*
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