First Name
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Last Name
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What Is An Ideal Day For An Appointment ?
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Monday
Tuesday
Wednesday
Thursday
Friday
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Indicate Ideal Time
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Morning
Afternoon
Anytime
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Where Is Your Pain?
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Lower Back
Mid Back
High Back
Neck
Shoulder
Knee
Ankle/Foot
Muscle From Sports injury
Other
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What Is Your Main Concern
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The Pain I'm Experiencing
Worrying over not knowing what's wrong
Concerns over no significant improvement
Avoiding painkillers
Staying active
Inability to perform at the gym
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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
Way too long (years)
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What Is The Main Goal That You Would Like Us To Help You Achieve?
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Ease pain
Ease Stiffness
Get Active
Avoid painkillers
Find out what is wrong
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What Does It Stop You From Doing?
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Where did you hear about us?
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Phone
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Email
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