Knee Pain Screening -

Do you have any of the following?
Select all that apply

How long have you had knee pain?

Less than 1 month 1 to 3 months 3 to 6 months More than 6 months

Is your pain the result of an accident?

Yes No

On a scale of 1 to 10 – what is your pain level?

1

Have you had knee surgery?

Yes No

Are you taking any prescription medication for your pain?

Yes No

Are you interested in a treatment option that is drug free and non-surgical?

Yes No

Your answers indicate:

You may be a candidate for treatment, but further information is needed to make an accurate diagnosis.

We would like to offer you a voucher for a free consultation so that we can better understand the source of your pain and provide you with the information you need to make an informed healthcare decision.

Who do we send the voucher to?

First Name

Last Name

Email

Phone

I have read and agree to the terms.

I consent to receive email, voice and text messages concerning the results of my pain screening and any treatment options that may be available to me. Reply with STOP to cancel at any time.