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"Pain Relief Through Muscle Balance" Clinical Trial Application
Complete and Submit The Application Below And You Will Be Notified Of Your Status By Email Or Phone Within 24 to 48 hours.
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First and Last Name
*
Your answer
Age
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Your answer
Street Address, City, State, Zip
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Your answer
Best Phone
*
Your answer
Primary Email Address
*
Your answer
Referred by
Your answer
Please describe the pain that is interfering with the quality of your life and rate it from 0-100 with 100 as worst.
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Your answer
What emotions come up for you as a result of your pain?
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Your answer
How has your pain negatively affected your life?
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Your answer
What would you like to be able to do that you're current pain is keeping you from enjoying?
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Your answer
Have you ever been diagnosed with fibromylagia?
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Choose
Yes
No
What is your percent willingness to make changes in your lifestyle habits?
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o% means... "I'll NEVER Change!" And 100% means..."I'll do whatever it takes!":
Your answer
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