What age group are you in?
20 - 29
30 - 39
40 - 49
50 - 59
60 - 69
70 - 79
80 +

How often do you suffer from pain?
Daily
More than once a week
Once a week
Once a month
Occasionally


What types of pain do you suffer from? (check all that apply)

Back Pain
Joint Pain
Migraines
All over body pain
Other


On a level of 1-10 with 10 being high pain and 1 being little pain, please rate your pain level?
10
9
8
7
6
5
4
3
2
1


Title:

First Name:

Last Name:

Address 1:

Address 2:

City/Town:

State/Province:
Zip/Postal Code:

Country:

Best phone number at which to reach you:

Best time to be contacted at the number provided:

Email:

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