*Primary Reason For Wanting To Speak With A Specialist Which Option Best Describes You?
1. I'm in lots of pain and want some advice I can start using right away
2. I would love to know what's wrong and how long it will take to ease
3. I'm not sure if Physical Therapy is right for me and talking to a Physical Therapist first would help me decide
4. I am having bladder issues and want to know if Physical Therapy can help
Where Does It Hurt? Which Option Best Describes You?
1. Back
2. Knee
3. Hip
4. Shoulder/Neck
5. Sports or Exercise Injury
6. Foot/Ankle
7. Not sure where it's coming from?
8. Pelvis
9. Other
What Does It STOP You From Doing?
*What Is Concerning You The Most? What Option Best Describes You?
1. The pain you are experiencing
2. Fear of not being able to keep active
3. Worry about not knowing what's wrong
4. Want to avoid painkillers
5. Concern at no signs of improvement
6. Future ill health (and wanting to prevent it)
7. Public embarrassment from incontinence
8. Difficulty with intimacy and/or conception
*How Long Have You Suffered Or Worried? What Option Best Describes You?
1. A Few Days
2. 1-2 Weeks
3. 2-4 Weeks
4. 1-3 Months
5. Long Enough
6. Too Long(Years)
*Best Time For A Call Back What Option Best Describes You?
1. During The Day
2. After 5pm
3. Anytime
*Best Day For A Call Back What Option Best Describes You?
1. Monday
2. Tuesday
3. Wednesday
4. Thursday
5. Friday
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