Step 1 of 6

Are you under or over the age of 50?

Under 50

Over 50

Step 2 of 6

Where is your pain located?

Neck

Shoulder

Back

Hip

Knee

Other

I do not have pain

Step 3 of 6

How long have you been suffering?

less than 3 months
3 months to a year
1-5 years
More than 5 years
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Step 4 of 6

What was recommended for your chronic pain?

Pain Pills/Anti Inflammation Pills

Physical Therapy

Cortisone Injections

Other Injections

Surgery

Nothing

Step 5 of 6

First Name

Last Name

Email *

Phone *

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