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(305)670-0055
9425 Sunset Dr. Ste 130
Miami, FL 33173
Home
Treatment
Nerve Beam
Nerve Spa
Supplements
Vibration
Peripheral Neuropathy
Patients
Dr. Chris Goetz
Home
Treatment
Nerve Beam
Nerve Spa
Supplements
Vibration
Peripheral Neuropathy
Patients
Dr. Chris Goetz
Tell Us About Your Pain
What is your current level of pain?
0 (no pain)
1
2
3
4
5
6
7
8
9
10 (extreme pain)
What is your source of pain? (check all the apply)
General Pain
Tingling
Pins & Needles
Burning
Numbness
Arms/Hands
Feet
legs
Back
Other
What type of doctors have you seen for your pain? (check all the apply)
General Doctor
Chripractor
Orghopedic Surgeon
Neurologist
Pain Management
Other
None
When did your pain begin?
Less than a month ago
1-3 months ago
4-12 months ago
more than a year ago
What medications or treatments are you receiving for your pain? (check all that apply)
Accupuncture
Cymbals
Lyrica
Muscle Relaxants
Neurontin
NSAID
Opioid Pain Medication
Physical therapy
Other/Unsure
None
Check any of the following tests you have had for this condition. (check all that apply)
CAT scan
EMG
MRI
X-ray
Other test
none
How serious do you view your condition?
Do you have any additional information about your condition you want us to know or any questions about treatment options we can help answer?
What Is Your First Name?
What Is Your Last Name?
What is your email address?
What is your phone number?
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