Name
*
Primary reason for wanting to speak with a Physical Therapist
*
I'm in a lot of pain and want some tips and advice I can use right away
I would love to know what's wrong and how long will it take to get some relief
I'm not sure what's wrong and talking to a specialist would help me understand better
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Where does it hurt?
*
Back Pain
Knee Pain
Shoulder Pain
Neck Pain
Foot / Ankle Pain
Muscle injury from Sport / Exercise
Postnatal Back Pain
Headaches / Migraines
Hip Pain
A problem where you are not sure where it's coming from
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What does it stop you from doing?
*
What concerns you most?
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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 you suffered or worried?
*
Haven't - this prevention (not cure)
A few days
1-2 weeks
About a month
> 3 months
Seems too long (years)
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Main goal of using our specialist service
*
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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Best Time For A Call Back
*
Morning
Afternoon
After 5pm
Anytime
Phone
*
Email
*
How did you hear about us?
*
Google
Yelp
Friend/Family Referral
Physician Referral
Event
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