Date of birth
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What issue do you want to discuss?*
Back Pain
Neck Pain
Shoulder Pain
Knee Pain
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Reduced Mobility
Difficulty Completing a Task or Sport
Other
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How long have you had this issue?*
A Few Days
1-2 Months
3-5 Months
Over 6 Months
Over a Year
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Yes
No
Does this issue prevent you from being able to work?
Yes
No
Does this issue prevent you from being able to exercise?
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Does this issue keep you up at night?
Preferred day of the week for your call
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Tuesday
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What time of day suits you best?
AM - 9am to 12 Noon
PM - 12pm to 4pm
EVENING - 4pm to 7pm
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