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BNXT LVL
HEALTH IS YOUR GREATEST ASSET
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ONLY THOSE WHO ARE SERIOUS ABOUT LEVELING UP THEIR HEALTH,
SHOULD HIT NEXT.
How long has this been going on?
(required)
Multiple Choice (required)
0-3 Months
3-12 Months
1-3+ Years
What Triggers it most?
(required)
Multiple Choice (required)
Sitting
Bending & Lifting
Training
Walking
Twisting
Not Sure
Do you have symptoms into the leg?
(required)
Shooting pain, Numbness, or tingling into leg/foot?
Yes
No
Have you been diagnosed with disc bulge/hernation or Sciatica?
(required)
Select one option
Yes
No
Not Sure
How much is this impacting your life right now?
(required)
Multiple Choice (radio) (required)
Mild annoyance, but I'm functioning
Moderate- affects training/work/sleep
Severe- I'm changing my life around it
what do you want to be able to do again without worrying about your back/hips?
(required)
What have you tried before?
PT
Chiro
Massage/Stretching
Meds/Injections
Youtube/Self Help
Nothing
What do you think is missing from what you’ve tried?
(required)
If we built a plan that clearly fits your situation, are you ready to follow it consistently for 3-6 Months?
(required)
Yes
Maybe/depends
No
A proper plan usually requires some investment. If accepted, are you currently able to invest in professional help?
(required)
Yes
Maybe/depends
No
If “maybe/no,” what would need to change for you to be able to move forward?
(required)
Yes
Maybe/depends
No
First Name
(required)
Phone number
Email
(required)
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