Please tell us...
Please Enter Your First Name
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What type of problem are you having?
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Please select one
Bladder Leakage
Urinary frequency/urgency
Bowel issues
Bladder pain
Abdominal pain
Pelvic pain
Pain with intercourse
Pain during pregnancy
Postpartum pain
Back pain
Not Sure Where It's Coming From
What Does It STOP You From Doing?
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Your Main Concern
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Please select one
The pain you are experiencing
Fear of not being able to keep active/involved
Fear of being in social situations
Worry about not knowing what's wrong
Want to avoid medications
Concern at no signs of improvement
Wanting to prevent future health problems
How Long Have You Suffered Or Worried?
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A Few Days
1-2 Weeks
2-4 Weeks
1-3 Months
Long Enough
Too Long (Years)
What do you value most when making your decision to choose a Physical Therapist? (check all that apply)
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Natural Treatments
Hands on care (example: massage, manual therapy, etc.)
One-on-one care
Home Exercises To Speed Up Your Recovery
The Main Goal You Would Like Us To Help Achieve For You
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Please select one
Ease pain
Stay active or involved in social activities
Avoid taking medications
Avoid surgery
Find out what's wrong
Stay healthy and get better before problem gets worse
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So we can rush the cost and availability of the service you have requested, please let us know your:
Best Phone Number
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Best E-mail
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