Name *

First Name

Last Name

1. Where is your primary pain located?

Head/Neck

Middle Back

Lower Back/Hips

Wrist/Elbow/Hand

Knee/Ankle

Foot

Other

2. How long have you been experiencing your symptoms?

Less than 6 months

6 months to 1 year

More than 1 year

3. How often do you experience your symptoms?

25% of the day or less

50% of the day

75% of the day

My symptoms are constant

4. Is your pain due to a recent accident or injury?

Yes

No

5. Are you currently taking NSAIDS or Steroids?

Yes

No

6. Are you currently pregnant?

Yes

No

7. Are you currently diagnosed with a malignancy (cancer)?

Yes

No

8. Are you interested in learning how laser therapy helps chronic and acute muscle pain and injuries?

Yes

No