First Name
*
Last Name
*
Where Does It Hurt?
Where Does It Hurt?
Pelvic muscles
Pregnancy Concerns
Postpartum Recovery
Hip Pain
Back Pain
Knee Pain
Neck & Shoulder Pain
Sports Injury
Not sure where it is coming from
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What does it stop you from doing?
*
Primary reason for wanting to sample Physical Therapy
*
What concerns you most that makes you want to sample physical therapy?
*
What concerns you most that makes you want to sample physical therapy?
Not knowing what's wrong
You want to avoid depending upon medications to manage symptoms
Not having the birth you envisioned
The risk of facing dangerous surgery due to chronic pain
Not being able to workout like you want to
Losing my ability to care for my family
Other
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How Long Have Your Suffered Or Worried?
*
Haven't - this is prevention not cure
1-2 weeks
2-4 weeks
1-3 months
Long enough
Seems like too long (years)
How Long Have Your Suffered Or Worried? *
What would be the one thing you would like us to achieve for you?
*
What would be the one thing you would like us to achieve for you?
Ease pain
Ease stiffness
Get active
Stay active
Avoid painkillers
Find out what's wrong
Stay healthy and get fixed before it gets worse
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Phone
*
Email
*
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