Multi-step form

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Multi-step form

How is this issue currently impacting your daily life?

💆 Neck or Shoulders

🧍 Back or Lower Back

🦵 Knee, Hip, or Leg

💪 Arm, Elbow, or Wrist

🩹 Post-Injury / Accident Recovery

❓ Other / General Discomfort

Additional comments (optional)

Personal Information:

Step 2 - 4

How would you describe the type of discomfort you feel?

Select all that apply.

Constant ache / dull pain Always there in the background

Sharp pain while moving Triggers when bending, lifting, or turning Stiffness or tightness Especially in the morning or after sitting Numbness or tingling Pins and needles feeling down arms or legs Throbbing or burning sensation Weakness or instability Feels like the joint/muscle might give out

How is this issue currently impacting your daily life?

Step 3 - 4

Keeping me awake at night / disrupting sleep Making work or sitting difficult Stopping me from working out or playing sports Limiting simple daily movements — walking, bending, lifting Just starting to feel uncomfortable

Have you tried any treatments or care for this yet?

Step 4 - 5

No, looking for guidance on where to start Tried at-home rest, stretch, or ice Tried other care — chiro, massage, or doctor — with limited results

Finish:

Step 5 - 5

Where should our physical therapy team send your assessment & recommendations?

Name *

Please enter your name.

Phone Number *

Please enter a valid phone number.

Email Address *

Please enter a valid email address.

✓

Thank You!

Your assessment has been submitted successfully. Our team will review your responses and contact you using the details provided.