If you are in pain and would like to chat with one of our expert pain coaches on our podcast, please answer the following questions to the best of your ability. We will contact you via email if you are determined to be an appropriate candidate!

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* 1. Full Name:

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* 2. Email Address:

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* 3. Date of Birth:

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* 4. Sex:

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* 5. How did you find the Pain Reprocessing Therapy Center?

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* 6. What chronic symptoms are you experiencing?

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* 7. When did your symptoms begin?

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* 8. Did you suffer from an injury? If so, when? Please describe.

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* 9. Do you have any test results/MRI findings? If yes, please describe.

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* 10. What is your current functionality?

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* 11. What do physicians say is the cause of your symptom(s)?

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* 12. What do you think is the cause of your symptom(s)?

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* 13. Did your symptoms begin during a time of stress, or do you notice your symptoms increase/get worse during stressful times?

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* 14. Are there any variations in the consistency of your symptoms (intensity, location, triggers, time of day, etc.)?

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* 15. Do you currently or have you previously suffered from (check all that apply):

Anxiety and/or Panic Attacks

Depression

Eating Disorder

Trauma

Suicidal Ideation

None of the above