590 Newark Ave Suite 2 - Jersey City, NJ 07306
(201) 420 – 1165
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Home
Physical Therapy
Chiropractic
Help & Advice
Job Openings
spinal decompression
Partner
Paterson Office
Passaic Office
Contact
Check Your Medical Symptoms
What is the level of pain you are experiencing? (10 being most severe)
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1
2
3
4
5
6
7
8
9
10
Where is the source of your pain?
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What type of doctors have you seen for your pain?
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Chiropractor
Pain Management
General/Family Doctor
Where is your pain begin?
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Headaches
Neck or shoulder pain or stiffness
Back pain
Abdominal pain or swelling
Numbness
Have you had any of the following treatments/procedures?
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Epidural Steroid Injection
Joint Injection
Trigger Point Injection
Nerve Block
Check any of the following tests you have had for this condition?
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MRI
X-ray
Have you had any surgeries relating to your existing pain or any prior pain conditions?
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Yes
No
Do you have any type of health or medical insurance?
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Yes
No
Do you have any additional information about your pain you want us to know or any questions about treatment options we can help answer?
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Have you had any of the following treatments/procedures? Epidural Steroid Injection Joint Injection Trigger Point Injection Nerve Block
*
Knees Surgery
Shoulder SX
What is your email?
*
What is your name?
*
Phone Number
*
zip code
*
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