Identifying and Defining Pain
This survey will help us understand your pain points and how you define a successful treatment.
Email address *
First Name *
Your answer
Last Name *
Your answer
Today's Date *
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I want information, recommendations or tips on injury prevention and wellness associated with: disc herniation, Sciatica and/or neuropathy issues via email, e-newsletter or postal mail.
What happened that made you look for Troy Neuropathy Center? *
Your answer
What types of pain or symptoms do you feel and where do you feel it? (Check all that apply.) *
Neck
Arm(s)
Hand(s)
Back
Leg(s)
Foot/Feet
Other
Burning
Tingling
Numbness
Radiating
Shooting Pain
Irritation
Weakness
Spasms
Overactive Reflexes
Can't Walk
Other
If you selected "other," please describe the type(s) of pain you feel and the location felt.
Your answer
What is your biggest challenge while in pain? *
Your answer
What does your pain prevent you from doing? *
Your answer
What would make life easier? *
Your answer
What is your experience with chiropractors? Rate your experience on a scale of 1-5. *
Not comfortable with and/or knowledgable of chiropractors
Very comfortable with and/or knowledgable of chiropractors
How knowledgeable are you about herniated discs? Rate your knowledge on a scale of 1-5. *
Not comfortable with and/or knowledgable of herniated discs
Very comfortable with and/or knowledgable of herniated discs
Have you considered surgery? *
What would you consider a successful treatment to look like? *
Your answer
What is your preferred method of learning? (Check all that apply.) *
Required
If you selected "other," please describe the method(s) of learning that you prefer.
Your answer
A copy of your responses will be emailed to the address you provided.
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