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Joint & Back Health Questionnaire

Fill out the form below and click "Submit"
to send us your information for evaluation.

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Name*:

Email*:

Do you have aches and pains in any of your joints, such as your knees, back or hands?*:

Yes No

Have you been taking medication for joint pain?*:

Yes No

Do you have an old joint injury that’s been acting up?*:

Yes No

Do you have back problems?*:

Yes No

Do you have numbness or tingling in your any of your extremities?*:

Yes No

Do you have burning in any of your extremities?*:

Yes No

Do you feel pins and needles in any of your extremities?*:

Yes No

Do you have difficulty walking?*:

Yes No

Have you experienced a decrease in your ability to reach without pain?*:

Yes No

Has your range of motion decreased?*:

Yes No

Do you experience pain relief with regular stretching and range of motion exercises?*:

Yes No

Are you overweight? (This can cause extra pressure on your knees)*:

Yes No

Do you experience cold hands or feet?*:

Yes No

Do you have frequent leg or foot cramps?*:

Yes No

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