Full Name
Phone
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Email
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How long have you struggled with pain?
On 1- 10 scale. How would you rate your daily pain?
On 1- 10 scale. How much does pain affect your day-to-day activities?
On 1- 10 scale. How much does pain affect your work?
On 1- 10 scale. How much does pain interfere with your family life?
Did you receive any treatments for your pain? If so which one?
How effective were these treatments?
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