Pain Management in NH
Pain Management in NH
First Name

Last Name

Email (we will keep your email completely private)

Please describe any pain symptoms you are experiencing.

Please rate your pain using the Pain Level Scale of 0-10 (0=no pain 10=severe pain)

What are your physical limitations? Please describe.

What position(s)/activities INCREASE your pain symptoms? Please describe.

What position(s)/activities DECREASE your pain and make you feel better? Please describe.

Do you have trouble sleeping due to pain?
Yes
No

What time of the day do you have the most pain?
Morning
Afternoon
Evening
Sleeping
All Day

What are the goals you hope to accomplish by doing Online Postural Therapy? Please describe.

Length of time you are willing to commit to a menu of corrective exercises.
30 Minutes
45 Minutes
60 Minutes
75 Minutes

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Eliminates chronic pain such as:

Migraine & Other Headaches - TMJ - Stiff Neck & Neck Pain
Herniated Discs - Stenosis - Carpal Tunnel - Shoulder Pain
Bursitis - Tendinitis - Back Pain - Hip Pain - Sciatica - Knee Pain
Shin Splints - Sprained & Weak Ankles - Hammertoes - Bunions
Calluses & Corns - Heal Spurs - Plantar Fasciitis