First Name *
Last Name *
Email *
Phone
City *
State
Country *
I am completing this candidate assessment for?
MyselfA friend or family member
Please select you or your friend/family member's gender
MaleFemale
How long have you or your friend/family member been suffering from pain?
Less than 6 months6 to 12 monthsMore than 12 months
What type of pain is being experienced? (Select all that apply):
Back PainNeck PainShoulder PainArm & Wrist PainHernia PainPelvic PainS.I. Joint PainFoot & Ankle Pain
Rate the average daily pain level over the past 30 days.
MildModerateExtreme
Which pain treatments have you or your friend/family member tried? (select all that apply)
Physical TherapyChiropractic CareSpine SurgerySpinal Cord StimulationEpidural InjectionsNerve AblationImplantable Pain PumpNone of the Above
Does pain keep you or your friend/family member from? (select all that apply):
Getting SleepWorkingBasic Household TasksEnjoying Time with FamilyWalking or ShoppingHobbies & ActivitiesNone of the Above
Which statement best describes you or your friend/family member best?
Exploring OptionsSeeing a SpecialistConsidering a TrialScheduled a TrialScheduled an ImplantCurrently using an Implant
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