Sunset Hills Spine and Joint Center $37 Voucher

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Who are you filling this out for? *

Myself

Husband

Wife

Daughter

Son

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What symptoms are you experiencing? *

Neck pain or stiffness

Back pain or discomfort

Headaches or migraines

Joint pain or stiffness (shoulders, knees, hips, etc.)

Numbness, tingling, or weakness in arms or legs

All of these above

Some of these above

How long have you been experiencing these symptoms?

Less than a week

1–4 weeks

1–3 months

More than 3 months

Symptoms come and go

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