First we will ask some questions about your pain condition.

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  • Step 2
  • Step 3

Tell Us About Your Pain

What is your current level of pain? If your pain comes and goes then choose how severe the pain is on a typical pain episode.

What is your source of pain? (check all that apply)

What type of doctors have you seen for your pain? (check all that apply)

When did your pain begin?

What medications or treatments are you receiving for your pain? (check all that apply)

How Did it Happen?

How did the pain begin? (check all that apply)

Check any of the following tests you have had for this condition. (check all that apply)

Have you had any surgeries related to your existing pain?

Have you had any of the following treatments /procedures? (check all that apply)

Tell Us About Yourself

Do you have any type of health or medical insurance?

How serious do you view your condition?

Do you have any additional information about your condition you want us to know or any questions about treatment options we can help answer?

What Is Your First Name?

What is your Last Name?

What is your best email address? (used to send treatment qualification information)

What Is Your Best Contact Phone Number - Please Input Your Area Code Followed By Your Phone Number With NO SPACES, No Dashes, Or Parentheses

What Is Your Zip Code?

What is the best time to contact you?

All Survey data is collected in a confidential manner: no uniquely identifiable information about survey respondents will be gathered and/or shared at any time. The contents of this web site are for informational purposes only. This site is not intended to furnish medical advice to anyone. Any diagnosis, treatment or care of a patient should be discussed with a physician.