Free Spine Health Checkup

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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.

Name *

Age

Gender

Male

Female

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Phone Number *

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

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Are you experiencing pain in your legs?

Yes

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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

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Do you have difficulty walking?

Yes

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Do you have trouble maintaining balance while walking?

Yes

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Have you had any previous spine surgeries?

Yes

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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

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Have you undergone an X-ray or MRI for your spine?

Yes

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Submit

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