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First Name *

Last Name *

Phone Number *

Email *

Primary point(s) of pain
Low backNeckButtocksHip(s)Leg(s)

If Other please specify:

How long have you had the pain?
Less than 4 weeksLess than 8 weeksLess than 6 monthsOver 1 year

Describe pain (best as possible)
DullBurningSharpTinglingNumbnessShootingThrobbing

Frequency of pain
Less than 4 hours/dayLess than 8 hours/dayConstant

When is pain worst (e.g. night, activity, etc.)

Have you been diagnosed with?
SciaticaProlapsed discHerniated discDisc bulgeStenosisDisc degenerationSpondylolisthesisNone of them

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