1. Name

2. Address

3. Practitioner

4. Is this your first course of PAM treatments?

Yes

No

5. What is your age group?

Please select from the dropdown list.

6. What areas were affected and how effective was the treatment?

Please select from the dropdown lists where applicable.

Neck

Lower back

Arm/Shoulder

Legs/Feet

Hips

Head

7. Have you had any of the following at any time in your life?

Motor accident

Serious fall

Sports injury

Rheumatoid arthritis

8. Have you received or tried any of the following other treatments for back pain?

Chiropractic

Osteopathy

Surgery

Alexander Technique

Physiotherapy

Homeopathy

Podiatry

Hospital Treatment

9. How long have you had episodes of back pain? Please select from the dropdown list.

10. Can you describe how PAM has helped you in a short paragraph?

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