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Ready to move without discomfort?
Answer a few quick questions to get started on your recovery.
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1
Where is your main area of discomfort?
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Select all that apply
Neck / Cervical
Knee / Leg / Foot
Mid-Back / Thoracic
Headaches / Jaw (TMJ)
Lower Back / Lumbar
Mid-Back / Ribs
Shoulder / Arm
Wrist / Hand / Elbow
Other
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2
How would you describe the pain you are experiencing?
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Select all that apply
Ache
Dull
Shooting pain
Electrical
Numbness/Tingling
Pins and needles
Stabbing
Weakness
Muscle Spams
Decreased Movement
Burning
Radiating
Other
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3
When did the pain start?
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Choose the best option
Today
1-3 days
4-7 days
More than a week
More than a month
On/Off for a year or more
I cannot remember
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4
How would you rate your pain?
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10 is the worst pain possible
1
2
3
4
5
6
7
8
9
10
Mild
Severe
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5
Do you know what might have caused this discomfort?
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Select all that apply
Car or bike accident
Sitting for long hours
Sports or exercise injury
Poor posture or desk work
Slip or fall injury
Stress
Work-related incident
Developed over time / Repetitive
Past injury
No known cause / Not sure
Other
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6
Does your pain or discomfort limit you?
*
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Select all that apply
Movement / Daily Activities
Exercise or Lifting
Sitting or Standing
Walking or Running
Sleeping or Resting
Playing Sports or Hobbies
Working or Productivity
Taking care of family/children
Breastfeeding or Baby Care
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7
What are some milestones you want to achieve?
*
This field is required.
Move Without Discomfort
Sleep Better
Work Comfortably
Return to Sports
Play With My Kids / Family
Drive Comfortably
Improve Mobility
Avoid More Invasive Options
Other
Maintain My Health
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8
Let's connect about your care!
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Tell us a bit about yourself, and we’ll reach out via phone or email to discuss how we can help.
First Name
Last name
Please enter your phone
Please enter your email
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Call
Text
Email
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Call
Text
Email
Preferred method of contact
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Morning
Afternoon
Evening
Weekends
Anytime
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Morning
Afternoon
Evening
Weekends
Anytime
Best time to reach you
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