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FREE Pain Relief Evaluation


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* Required Fields

* First Name:

* Last Name:

*  City:

*  State:

*  Email Address:

*  Phone:

*  How did you hear about us?:

* What are your health goals? (Choose all that apply) :








Additional Health Goals:

*  Are you currently in pain?:



*  Is your pain constant?:



*  What are your primary areas of pain?:
   (e.g. Lower Back Pain, Shoulder Pain etc...)

*  Have you experienced this pain in the past?:

*  In addition to your pain, are you now experiencing any of the following? (Check all that apply):






*  What makes your pain worse?:

*  Which of the following have you tried for the management of your pain? (Check all that apply):














     Other things you've tried for the management of your pain?:

*  How helpful were these treatments in reducing your pain?:




*  Have you visited any of the following specialists?:







     Other specialists visited?:

*  Are you currently in a pain relief program with a healthcare provider?:



     If you answered yes to the question above, which type of provider(s) are you treating with? :

* How frequently do you exercise?:

* What is your current weight in pounds?:

* What is your height?:
Feet Inches

* What is your age?:

*  Are you interested in starting a nutrition and fitness program to help ease your pain?:


If yes, we'll send you information about The MaxReliefRx™ Pain & Weight Control Plan including nutritional supplements and easy to follow anti-inflammatory diet.

*  Are you also interested in losing weight to help further reduce your pain?:



  If you answered yes to the question above, how many pounds would you like to lose?:

* What type of consultation would you prefer?:




Important:
If you selected either face to face or telephone consultation in the question above, please enter the best telephone number for us to reach you.

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