Thanks For Scheduling Your Appointment

Thanks For Scheduling Your Appointment!

In order for us to best prepare for your appointment, please complete this brief survey below within the next 10 minutes:

Do You Suffer From Knee Pain? *

Yes

What is the problem you are experiencing? (Check all that apply) *

Knee Pain

Peripheral Neuropathy

Lower Back Pain

On a scale of 1-10, one being hardly any pain and ten being unbearable, how would you rate your pain? *

Describe your Pain / Discomfort (Select all that apply) *

Sharp

Aching

Burning

Stiffening

Numbness & Tingling

How long have you been dealing with this problem? *

0-3 months

3-12 months

1-3 years

Over 3 years

How many doctors have you seen for this problem? *

None

What have you tried in the past that has not corrected your problem? (Check all that apply) *

Steroid injections

Aspirin, Tylenol or Advil

Prescription Pain Medications

Physical Therapy

Surgery

Knee Replacement Surgery

What activities are being negatively affected? (Check all that apply) *

Walking

Sit to stand

Squatting

Kneeling

Running

Leisure Activities

(Golf, Tennis, Swimming, Biking, etc.)

What aspects of your life are being negatively impacted? (Check all that apply) *

Marriage / Relationships

Ability to Exercise

Work

Mood

Sleep

On a scale of 0 - 10, how important is it for you to get this problem corrected? (Ten being most important) *

Please confirm your details are correct:

First Name *

Last Name *

What is your email? *

What is your phone number? *

West Coast Wellness

4361 Aidan Lane, North Port, FL 34287 | (941) 429-0070

Offer cannot be used with any federal programs such as Medicare or Medicaid. Not valid with any other promotions.