First Name
*
Last Name
*
Primary reason for wanting to sample Physical Therapy
*
Where does it hurt?
*
Where does it hurt?
Back Pain
Knee Pain
Neck & Shoulder Pain
Sports Injury
Balance & Falls
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What does it stop you from doing?
*
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 painkillers to ease pain
Losing mobility or independence due to chronic pain
The risk of facing dangerous surgery due to chronic pain
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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)
What would be the one thing you would like us to achieve for you?
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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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