Pain Relief Consultation Request Form


11295745 1120163254665950 5070189675025569459 nPlease answer each of the questions listed below. Be sure to include the best contact phone number for you so that our staff can schedule your Pain Relief Consultation. All fields in red are mandatory.

* 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.

Birthday Club:

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Please enter your birthday below (Month & Day required):

Comments:

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