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Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Do you ever experience pain flare ups?
(Required)
Select One:
All of the time.
Sporadically.
Never.
Where do you experience pain?
(Required)
Knee
Achilles
Ankle/Foot
Lower Back/Hips
Shoulder
Other
Does The Pain Effect Your Ability To Work?
(Required)
Select One:
Yes
No
What Do You Do For Work?
(Required)
Select One:
Accounting/Finance
Advertising/Public Relations
Aerospace/Aviation
Arts/Entertainment/Publishing
Automotive
Banking/Mortgage
Business Development
Business Opportunity
Clerical/Administrative
Construction/Facilities
Consumer Goods
Customer Service
Disability
Education/Training
Energy/Utilities
Engineering
Government/Military
Green
Healthcare
Hospitality/Travel
Human Resources
Installation/Maintenance
Insurance
Internet
Job Search Aids
Law Enforcement/Security
Legal
Management/Executive
Manufacturing/Operations
Marketing
Non-Profit/Volunteer
Pharmaceutical/Biotech
Professional Services
QA/Quality Control
Real Estate
Restaurant/Food Service
Retail
Sales
Science/Research
Skilled Labor
Technology
Telecommunications
Transportation/Logistics
Unemployed
Other
Other
(Required)
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Please Do Not Fill Out This Form Unless You Truly Want To Eliminate Your Pain
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*
" indicates required fields
First Name
*
Last Name
*
Email
*
Phone
*
Fake Phone Numbers Will Not Be Accepted
Do You Ever Experience Pain Flare Ups?
*
Select One:
All of the time.
Sporadically.
Never.
Where Do You Experience Pain The Most?
*
Achilles
Ankle
Hip
Knee
Lower Back
Neck
Upper Back
Shoulder
Other
Other - Pain location
*
Are You Currently Employed?
*
Select One:
Yes
No
What Do You Do For Work?
*
Select One:
Accounting/Finance
Advertising/Public Relations
Aerospace/Aviation
Arts/Entertainment/Publishing
Automotive
Banking/Mortgage
Business Development
Business Opportunity
Caregiver
Cashier
Clerical/Administrative
Construction/Facilities
Consumer Goods
Customer Service
Disability
Driver
Education/Training
Energy/Utilities
Engineering
Entrepreneur
Fitness
Government/Military
Green
Healthcare
Homemaker
Hospitality/Travel
Human Resources
Installation/Maintenance
Insurance
Internet
IT
Job Search Aids
Law Enforcement/Security
Legal
Management/Executive
Manufacturing/Operations
Marketing
Non-Profit/Volunteer
Pharmaceutical/Biotech
Professional Services
QA/Quality Control
Real Estate
Restaurant/Food Service
Retail
Retired
Sales
Science/Research
Self-Employed
Skilled Labor
Teacher
Technology
Telecommunications
Trade
Transportation/Logistics
Unemployed
Warehouse
Other
Other
*
Does The Pain Affect Your Ability To Work?
*
Select One:
Yes
No
What In The Past, If Anything, Have You Tried To Resolve Your Pain?
*
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