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First Name
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Last Name
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Email
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Phone
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Do you have Pain? If So, Where Does It Hurt?
Back
Lower Back
Neck/Shoulders
Knee
Leg
Hip
Foot/Ankle
Pelvic Region
Arm/Wrist/Elbow
Headaches/Migraines
Muscle Injury From Sport or Exercise
Not Sure Where it's Coming From
I Don't Have Any Pain Right Now
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If Yes to Pain: How Long Have You Struggled With This Problem?
Haven't, no pain- this is prevention (not cure)
A Few Days
1-2 Weeks
2-4 Weeks
1-3 Months
Long Enough (4+ months)
Seems Like Too Long (Years)
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