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Discovery Virtual Visit
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Name (First, Last)
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Your answer
Email
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Your answer
Phone
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Your answer
Are you currently pregnant?
Yes
No
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If yes, how many weeks?
Your answer
How many weeks postpartum are you?
Less than 6 weeks
More than 6 weeks but less than 6 month
More than 1 year
3+ years
N/A - I'm pregnant
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What kinds of symptoms are you experiencing? Check all that apply.
Low back pain
Upper back pain
Incontinence
Prolapse
Diastasis Recti
Pelvic Pain
SI joint pain
Other:
What Kind of Problems Are You Having?
Your answer
Are you a Maryland resident?
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Yes
No
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