Name *

Gender*

Date of birth*

City / State

Country

Where do you feel the pain?

When did you feel that pain for the first time?

Specify your pain

Which position or movement is the worst for you?

Did you ever have one of theses diagnostics for your problem?

Do you or did you have one of theses medical diseases?

Which position or movement is the worst for you?

Did you ever have one of theses diagnostics for your problem?

Do you or did you have one of theses medical diseases?

Have you ever been diagnosed with severe osteoporosis following an examination that measures bone density (bone densitometry)?

Did you ever have one of these imaging for your concern problem :

X-ray

MRI

Do you have a copy of the written medical reports?

**If you answer yes to one of these questions, we strongly suggest to bring a written copy of the result at the evaluation, if possible.

Where did you heard about our clinic?

Email adress *

Better phone number to join you *

I want to subscribe to newsletter (french only) *

Best time to join you by phone

Commentary