LASER THERAPY CAN PROVIDE YOU CHRONIC PAIN RELIEF Chronic Pain Quiz Could Integrated Pain Solutions Help You Win the Fight Against Your Chronic Pain? Please take just a few minutes to answer these 12 questions about your chronic pain. Please note that an asterisk (*) indicates a required field. Your answers will be reviewed by our team to see if you might be a candidate treatment at Integrated Pain Solutions. Gender * Male Female How old are you? * Under 30 30-39 40-49 50-59 60-69 70 or older Are you in pain for more than 10% of your day? * Yes No Where is your pain? (Press the CTRL key + click to select more than one) * Neck/Upper Back Arms Shoulders Low Back Hips Legs Knees Ankle Feet Other (please describe) Describe your pain (press the CTRL key + click to select more than one) * Burning Dull Ache Numbness Sharp Shooting Stabbing Tingling Throbbing Other (please describe) How long have you been in pain? * Less than 6 months 6 months - 5 years More than 5 years On a Scale of 1 to 10, what is the AVERAGE amount of pain you've had over the past 30 DAYS? (1=no pain, 10=worst pain you can imagine) * Does the pain interfere with your sleep? * Yes No Do you make decisions in your life based on your level of pain? * Yes No Do you know the source of your pain? Do you know what caused it? * Has another health care provider diagnosed the cause of your pain? If so, what diagnosis were you given? Is there anything else you'd like to tell us? Thank you for telling us more about your chronic pain. One of our doctors will review your answers to determine if you might benefit from our treatment. You will hear from us within 1-2 business days. First Name * Last Name Email * Phone * Best time of day to call How did you hear about us? * Finish >> SCHEDULE A NO-COST CONSULTATION TAKE OUR CHRONIC PAIN QUIZ SEMINARS
