Laser Therapy Questionnaire

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number* This field is required.

Please enter a valid phone number.

5

How long have you been experiencing your symptoms?* This field is required.

Less than 6 months

6 months to 1 year

More than 1 year

6

How often do you experience your symptoms?* This field is required.

25% of the day orless

50% of the day

75% of the day

My symptoms areconstant

7

Is your pain due to a recent accident or injury?* This field is required.

YESNO

8

Are you currently taking NSAIDS or Steroids?* This field is required.

YESNO

9

Are you currently pregnant?* This field is required.

YESNO

10

Are you currently diagnosed with a malignancy (cancer)?* This field is required.

YESNO

11

Are you interested in learning how laser therapy helps chronic and acute muscle pain and injuries? * This field is required.

YESNO

12

Please verify that you are human* This field is required.