Online Treatment Eligibility Survey

Please fill this in to the best of your ability.

Hey! I hope I'll be able to help you with your low back or pelvis pain, but let's start with your name!

First Name *

Last Name *

Great, I just need a few more details...

Email *

Mobile Number *

Date of birth *

Awesome. Let's get started...Where are you currently experiencing pain?

Pain Location *

Other pain location

Do you have motor weakness/numbness anywhere?

Motor Weakness Limb *

Yes

Do you have shooting pains down one or both legs?

Shooting Pains *

Yes

Are you open to exercises as part of your treatment plan?

Exercise As Part Of Treatment *

Yes

As part of your treatment it may be beneficial for you to receive hands-on, in-person treatment. Would you be interested in receiving this?

In Person Treatment *

Yes

How long has this pain been an issue?

Pain Duration *

Less than 1 month

Between 1 and 3 months

Between 3 and 6 months

Longer than 6 months

Do you have private medical insurance?

Private Medical

Yes

Who is your private healthcare provider?

Private Medical Provider

AXA/BUPA

Other

Thanks for filling in this enquiry form – you're eligible! Please click the submit button below to book an initial consultation with me!

Ciaran Keen

ciaran@ciarankeen.com