Step 1 of 8
Back Pain Protocol Survey
Before we begin please provide your contact information.  

If you are a good candidate for our back pain protocols, someone from our team will contact you within one business day.

Step 2 of 8
Back Pain Protocol Survey
Where are you currently experiencing back pain symptoms?  

Please select all that apply.

Step 3 of 8
Back Pain Protocol Survey
Which of the following activities cause your to experience back pain?  

Please select all that apply.

Step 4 of 8
Back Pain Protocol Survey
Duration of Condition:
How long have you been experiencing your symptoms?
Step 5 of 8
Back Pain Protocol Survey
Severity of Condition:
On a scale of 1-10 How would you rate the severity of your symptoms?
Step 6 of 8
Back Pain Protocol Survey
Previous Treatments:
What have you done in the past to treat your back pain?

Please select all that apply.

Step 7 of 8
Back Pain Protocol Survey
On a Scale of 1 – 10 with 1 being the lowest level of success and 10 being the highest, How well have you been able to manage your symptoms with your past treatments?
Step 8 of 8
Back Pain Protocol Survey
Treatment Goals and Expectations:
What are your primary goals and expectations from a treatment for your back pain?  

Please select all that apply.

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