Please tell us...
Please enter your first name
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Where do you have the MOST pain?
*
Please select one
back
hip
neck
TMJ
headache
knee
foot
shoulder
elbow
wrist & hand
whole body
What do your symptoms STOP you from doing?
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How long has this been bothering you?
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A few days
1-2 weeks
2-4 weeks
1-3 months
4-6 months
7-11 months
1 - 2 years
3 - 5 years
6 - 10 years
More than 10 years
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How much attention do you prefer?
Please select one
30 minutes
45 minutes
60 minutes
What is your MAIN concern?
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Please select one
Not knowing what's wrong
Depending upon painkillers
Losing mobility or independence
The fear of needing surgery
What do you value most when making your decision to choose a healthcare provider? (check all that apply)
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someone who will listen to your concerns
someone who will provide a thorough explanation of your problem
hands-on care (example: massage, manipulation, etc.)
one-on-one care
to learn things you can do at home to speed up your recovery
Other
What is the main goal you would like us to help you achieve?
*
Please select one
ease pain
improve stiffness
improve function
improve activity level
improve range of motion
sleep better
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So that we can reach you to answer your questions, please provide the following:
Best Phone Number
*
Best E-mail
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