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Free Spine Health Checkup
Fill out this form to receive a free spine health check! Our experts will review your responses and provide valuable insights and recommendations for your spinal well-being.
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Name
*
Your answer
Age
Your answer
Gender
Male
Female
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Phone Number
*
Your answer
Lifestyle
Sedentary
Active
Heavy Work/Lifting
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What type of pain are you experiencing?
Neck Pain
Mid Back Pain
Low Back Pain
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Are you experiencing pain in your arms?
Yes
No
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Are you experiencing pain in your legs?
Yes
No
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How long has your pain lasted?
Less than a week
Less than 2 weeks
Less than 3 weeks
More than 3 weeks
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Do you experience tingling or numbness?
Yes
No
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Do you have difficulty walking?
Yes
No
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Do you have trouble maintaining balance while walking?
Yes
No
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Have you had any previous spine surgeries?
Yes
No
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Do you have any existing medical conditions?
High Blood Pressure
Diabetes
Thyroid Disorder
All
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Do you smoke?
Yes
No
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Have you undergone an X-ray or MRI for your spine?
Yes
No
Clear selection
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