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Be Your Omni Best without hassle SURPRISE BONUSES form
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* Indicates required question
Email
*
Your email
Preferred Name as stated in previous form(s) (for easy identification)
*
Your answer
Where is your pain? (neck/shoulders/back/hips/knees/feet/etc)
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Your answer
Check the boxes that contain descriptions that are relevant to your pain (can have more than one):
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Ongoing; stayed with me on a regular basis for more than six months
Recurring; comes and goes with times that I feel fine and times that I feel the pain
Just happened recently
Other:
Required
Elaborate on your answer from above as needed.
Your answer
How badly does your pain affect you in your daily life?
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Not too bad. Living with it is uncomfortable, but I can get used to it.
1
2
3
4
5
6
7
8
9
10
Very badly! I want the pain to disappear right now!!
Describe how your pain affects you in your daily life.
Your answer
How long ago did it start?
*
More than 10 years ago
More than a year ago
More than 6 months ago
More than a month ago
Other:
Was there any past injury/impact/surgery that happened prior to the pain that you recovered from earlier that you can remember?
Your answer
Check the boxes that contain relevant descriptions to the treatments/methods/regimes you undergone to solve your pain (can have more than one):
*
Massage/manual therapy
Physio/physical therapy
Self-myofascial release
Yoga/pilates
Chiropractic/bone adjustments
TCM
Infrared Light Therapy
Heat rub (tiger balm oil, counterpain, etc) or patches
Pain killers through injection or oral medication
Other:
Required
Describe how the above attempts to solve your pain problem turned out.
Your answer
Is there some other method(s) you are currently trying or intending to? If so, which ones? (*This is important to avoid any possible contraindication*)
*
Your answer
A copy of your responses will be emailed to the address you provided.
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