Your Name
Your Email
Do you have a history of cancer? YesNo
Have you experienced recent unexplained weight loss? YesNo
Do you have a known immunosuppressive disorder? YesNo
Have you used steroids for a prolonged period of time? YesNo
Are you an intravenous drug user? YesNo
Do you have signs of a urinary tract infection? YesNo
Is your pain increased or not relieved by rest? YesNo
Do you have a fever? YesNo
Have you experienced trauma or had an accident? YesNo
Have you experienced bladder or bowel incontinence? YesNo
Do you have numbness or feel clumsy in both feet? YesNo