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FOR A FREE ONLINE EVALUATION FILL OUT THE QUESTIONNAIRE BELOW

Your First and Last Name:
Home Zip Code:
How did you hear of this web site?
What is your sex?MaleFemale
What is Age Range?
Where does it hurt?Head or FaceWrist, Hand or Forearm
(check all areas that are painful)NeckAbdomen
ShouldersFront of Pelvis
Middle BackHips or Thighs
Lower BackKnees
ChestShins
Arm or ElbowAnkle or Feet
Describe the most painful area  (use a 0-10 pain scale....0 being not painful 10 being excruciating)
When did it start, and what makes it better and worse?
If there's a second area of complaint, describe it here  (use 0-10 pain scale)
When did it start, and what makes it better and worse?
The reason for treatment is due to a:
Work Related Injury
Automobile Accident
Athletic Injury
Progressive-No one injury
Unknown
Describe any condition that may be related to your pain such as your general health
Would you prefer our response to be by phone or e-mail
Phone
Email
Please leave your e-mail or phone number so we can respond.
Describe Treatments You Have Received and Medications That You Are Taking
Are you currently:
Pregnant
Being Treated for Cancer
     
Be sure to click "SUBMIT FORM" to send all your information.
We will respond to you within 24-48 hours.



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