Full Name
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What day works best for an appointment?
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Monday
Monday
Tuesday
Wednesday
Thursday
Friday
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What times of day work best for an appointment?
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Morning
Morning
Afternoon
Late Afternoon
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Where Does It Hurt (if applicable)?
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Back
Back
Pelvis
Hip
Knee/Ankle
Abdomen
Neck
Shoulder
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What Does it STOP You From Doing?
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What is Your Main Concern?
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Not knowing what's going on
Pain
Leaking
Vaginal Heaviness/Pressure
Abdominal Muscle Separation
Birth Prep
Post Partum
Not Knowing What's Going On
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How Long Have You Suffered or Worried?
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Haven't - This is Prevention
A Few Days
1-2 Weeks
2-4 Weeks
1-3 Months
Long Enough
Seems Like Too Long (Years)
What Is Your Main Goal?
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Ease Pain
Ease Pain
Become Active
Stay Active
Avoid Surgery
Prevention
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How committed are you to solving this problem? (0 = not committed, 10 = very committed)
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10
0
1
2
3
4
5
6
7
8
9
10
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Phone
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Email
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