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Starting Your Journey to a Pain Free Life

Q.1
Please mark all that apply *
Rarely ( once a month or less) Occasionally (less than once a week) Frequently (More than once a week) Constantly
Do You Have Back or Neck Pain?
Do You have Headaches or Migraines?
Do you suffer from Arthritis?
Do You have Allergies?
Do You have Plantar Fasciitis
Have Heartbreak or Heartache
Suffer from Digestive Disorders
Can't Sleep
Have Anxiety
Other

Do You Have Back or Neck Pain?

Do You have Headaches or Migraines?

Do you suffer from Arthritis?

Do You have Allergies?

Do You have Plantar Fasciitis

Have Heartbreak or Heartache

Suffer from Digestive Disorders

Can't Sleep

Have Anxiety

Other

Q.2
What are your biggest challenges when it comes to any type of pain, sleeplessness or anxiety you are feeling *

Q.3
What have you tried to do to resolve this and how did that work for you? *

Q.4
What is not resolving this problem costing you? *

Q.5
How much longer are you willing to deal with this? *

Q.6
What do you want instead? *

Q.7
What would your life be like if you were able to be pain free and have a healthy vibrant life? *

Q.8
On a scale from 1 (low)-10 (high), how committed are you to becoming pain free and enjoy a more healthy, vibrant life? *

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