Allan M. Spiegel, M.D.
31608 US 19
Palm Harbor, FL 34684
727-269-5870
FREE Pain Relief Analysis
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Your Email Address:
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How did you hear about us?:
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What are your health goals? (Choose all that apply) :
Lose weight
Get in shape
Eat healthier
Reduce stress
Improve overall health
Reduce aches and pains
Detox and cleanse your body
Additional Goals:
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Are you currently in pain?:
Yes
No
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Is your pain constant?:
Yes
No
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Have you experienced this pain in the past?:
-- Please choose an option --
yes, once in the last 6 months
yes, more than once, including within the last 6 months
yes, once or more, but not within the last 6 months
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In addition to your pain, are you now experiencing any of the following? (Check all that apply):
extreme weakness in one or both leg
numbness in the groin or rectal area
a loss of bowel or bladder control
difficulty urinating
none of the above
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Tell me what makes your pain worse.:
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Which of the following have you tried for the management of your pain? (Check all that apply):
aspirin, acetaminophen, ibuprofen, or other nonprescription pain medication
cold pack or bag of ice on the painful area
heating pad or hot bath
massage
acupuncture
physical therapist,
chiropractic
treatment by a primary-care physician
prescription painkillers or muscle relaxants
bed rest for up to 3 days
bed rest for more than 3 days
dietary changes
none of the above
Other :
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How helpful were these treatments in reducing your pain?:
very helpful
moderately helpful
not helpful at all
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Have you visited any of the following specialists?:
chiropractor
orthopedist or other back specialist
psychologist or other mental health specialist
pain specialist
rehabilitation specialist or exercise physiologist
none of the above
Other:
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Are you currently in a pain relief program with a healthcare provider?:
Yes
No
If you answered yes to the question above, which type of provider are you treating with? :
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How frequently do you exercise?:
-- Please choose an option --
I never exercise
I workout once in a while
I workout 1-3 days a week
I workout 4-6 days a week
I workout every day
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What is your current weight in pounds?:
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What is your height?:
-- Feet --
3
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ft.
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in.
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What is your age?:
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Are you interested in starting a nutrition and fitness program to help ease your pain?:
Yes
No
If yes, we'll send you information about a new online anti-inflammatory diet plan called
MaxReliefRx™
.
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What type of consultation would you prefer?:
Face to face at our office.
Telephone consultation.
Not interested in a consultation at this time.
Phone:
If you selected either face to face or telephone consultation in the question above,
please enter the best telephone number for us to reach you.
Birthday Club:
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Meet
Allan M. Spiegel, M.D.
Dr Spiegel has been practicing neurology for 25 years in Palm Harbor, Florida..
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