What areas of your life are affected by the pain? Choose all options that apply.
Where is the source of your pain? Choose all options that apply.
Which side is more symptomatic
On a scale of 1-10, one being hardly any pain and ten being unbearable, how would you rate your pain?
How did the pain begin? Choose all options that apply.
Have you had any surgeries to your existing pain or any other pain condition?
Do you have any recent MRI or X-ray of the problem area?
Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.
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