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About your pain

How long have you had this problem ?

Describe the type of pain and frequency of the pain e.g Constant dull ache, intermittent sharp pain

About your pain

Do you have any numbness or pins and needles?

Do you have any pain referred into your legs or feet?

Have you noticed any problems with your bladder, bowels, any unsteadiness walking or any loss of strength in the arms or legs?

About your pain

What caused the injury e.g. no real cause just came on gradual, injury at work , playing sport, car accident etc

Is there any bruising or swelling?

Have you got full normal range of movement?

Were you able to continue with the activity or sport or did you have to stop?

Your Details

First Name

Last Name

Email Address

Contact Number

Post Code

Age

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