Pain Relief

Explain your symptoms or tell us how we can help today.*

Do you have allergies to any medications?*

Yes
No

If yes, please list any medications you have allergies to:

Are you pregnant or breastfeeding?*

Yes
No

Unfortunately we cannot proceed with your request based on the information you have provided.

What area(s) are affected?*

How does the pain feel?*

Dull
Throbbing/aching
Tingling or feeling of pins and needles
Sharp/stabbing
Constant
Sporadic
Hot or burning
Itching
Other

If you've listed "other", please explain your symptoms:*

Have you recently had a fall or traumatic injury?*

Yes
No

Does pain get worse when you do any of the following?*

Lying down
Standing
Sitting
Walking
Exercising

How Long have you been having these symptoms?*

Started today
1-3 days
4-7 days
Over 1 week

Have you ever been treated for asthma?*

Yes
No

How long ago?*

What medications were you treated with?*

Antihistamines
Nasal decongestants
Oral decongestants

What type of Oral decongestants?*

Pseudoephedrine
Oxymetazoline
Phenylephrine
Other

Did treatment work?*

Yes
No

Would you prefer the same treatment?*

Yes
No
Leave to doctor’s discretion

Smoker?*

Yes
No
Never

Alcohol use?*

Any medical family history?*

Yes
No

Please explain your medical family history:*

Do you have any medical conditions?*

Yes
No

Please explain your medical conditions:*

Have you ever had any surgeries or recent hospitalizations?*

Yes
No

Please explain your surgeries or recent hospitalizations:*

Do you currently take any medications, herbals, or supplements?*

Yes
No

Please list any medications, herbals, or supplements:*

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Pain Relief

Pain Relief

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