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First and Last Name:
Email Address:
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Telephone Number:
Best Time To Call:
Do You Suffer From Neck Pain? Yes No
Have You Experienced Neck Pain For Longer Than 30 Days? Yes No
How Severe Is Your Pain On A Scale Of 1 to 10? (10 being the worst)
How Long Have You Had It?
Does It Radiate Into Your Arms, Hands or Fingers? Yes No
Do You Feel Numbess or Tingling In Your Arms, Hands or Fingers? Yes No
Do You Feel Any Weakness In Your Arms, Hands or Fingers? Yes No
Do You Have Lower Back Pain? Yes No
How Severe Is Your Pain On A Scale Of 1 - 10? (10 being the worst)
How Long Have You Had It?
Does It Radiate Into Your Legs or Feet? Yes No
Do You Feel Numbness Or Tingling In Your Legs, Feet or Toes? Yes No
Do You Feel Any Weakness In Your Legs, Feet or Toes? Yes No
Have You Had An MRI? Yes No
How Long Ago?
What Type Of Treatment(s) Have You Had?
Have You Received Any Epidural Steroid Injections? Yes No
Have You Undergone Spine or Disc Surgery? Yes No
What Type Of Surgery Did You Have?
Was Any Metal Hardware Installed? Yes No
Do You Have Your MRI Films Or Disc? Yes No
Have You Been Given A Diagnosis? Yes No
What Diagnosis Were You Given?
Would You Like Us To Review Your MRI & Discuss It With You? Yes No
Would You Like To Schedule A FREE Evaluation? Yes No
Do You Have Any Specific Questions?