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Pain Questionnaire
Dr. Kelly Ashbeck, DPT, OCS, will review your case then contact you to discuss treatment options and answer your questions via email, text or call. There is no cost or pressure to schedule and appointment.
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* Indicates required question
Email
*
Your email
Name and Age:
Your answer
Describe your main complaint(s) and symptoms.
Your answer
Describe HOW and WHEN your symptoms began.
Your answer
List any important medical or injury history.
Your answer
What makes the symptoms better?
Your answer
What makes the symptoms worse?
Your answer
Have you seen any other health care professionals for this condition.
Yes
No
If yes, who did you see and what tests (X rays, MRIs, etc) and treatments were provided?
Your answer
Rate your level of function with 100% being normal.
Your answer
What are you looking to do that you are currently unable to do because of these symptoms.
Your answer
Any questions?
Your answer
Do you have a treatment preference?
Anything to help
Dry Needling
Pain education
Exercise and Rehabilitation
Manual Therapy (Joint and Soft Tissue Treatment)
Other:
How would you like to be contacted?
Email
Phone
Text
Leave phone # if that was your preference above.
Your answer
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