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485 E 17th St #510, Costa Mesa, CA 92627
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(949) 356-7548
#1 Back Pain Relief Program
in the
Costa Mesa area!
Get Back Pain Relief
Without
Drugs, injections, or Surgery!
Take this Short Questionnaire to See if You're Eligible!
Who is this for?
*
Myself
Spouse
Child
Parent
ip_address
What types of back pain symptoms are you experiencing?
*
๐๐ฎ๐ฅ๐ฅ, aching pain
๐๐ฎ๐ฌ๐๐ฅ๐ ๐ฌ๐ฉ๐๐ฌ๐ฆ๐ฌ or stiffness
๐๐ก๐๐ซ๐ฉ or stabbing back pain
Pain that ๐ซ๐๐๐ข๐๐ญ๐๐ฌ down the legs
Pain ๐ฐ๐ก๐ข๐ฅ๐ ๐ฐ๐๐ฅ๐ค๐ข๐ง๐ short distances
๐๐ข๐๐๐ข๐๐ฎ๐ฅ๐ญ๐ฒ ๐ฌ๐ญ๐๐ง๐๐ข๐ง๐ or sitting for long periods
On a scale of 1 to 5, how severe is your pain?
*
1๏ธโฃ Minimal discomfort
2๏ธโฃ Mild pain
3๏ธโฃ Moderate pain
4๏ธโฃ Significant pain
5๏ธโฃ Severe and debilitating pain
How long have you been experiencing these symptoms?
*
Less than 6 months
6 months to 1 year
1-3 years
Over 3 years
Have you been told by a doctor that you might need surgery?
*
Yes
No
Not sure
Have you been diagnosed with any of the following conditions?
*
Herniated or bulging disc
Sciatica
Stenosis
Scoliosis
Degenerative disc disease
I have not been diagnosed with a specific condition
What treatments have you tried for your pain?
*
Pain medications (e.g., opioids, NSAIDs, muscle relaxers)
Steroid injections
Surgery
I havenโt tried any treatments yet
Financing options are available based on credit approval. Which best describes your credit range?
*
Below 650
650-700
700-750
750+
What is your zip code? (This helps us ensure we are serving the right areas.)
*
Full Name
*
What is the best phone number to reach you?
*
Our Location
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