Tell Us About Your Pain Are you: Under 25 25 - 50 50 + Sex Male Female Where do you have pain? (You can check multiple boxes) Shoulders Back Hip Knee Ankle or foot Albow Hand or fingers How long have you been suffering with this? Under 3 months 3 - 6 months 6 months - 2 years 2 years + Which treatments have you tried? Physiotherapy Training on your own Surgery Other (Specify under) Other Have you ever had surgery? Yes No You feel pain...... Every day Every other day Every week Once a month What does the pain keep you from doing? How does this affect the people around you? Family? Friends? What is the first thing you would do if you didn't have pain? Do you want surgery? Yes No Is treating this problem/s a priority for you? Yes No If we think we can help, do you want us to contact you? If so, fill in your contact information and we will get in touch as soon as possible! Yes No First Name Last Name Email* Telephone Number* Submit
