Register here if you're a patient, or the friend or relative of someone who suffers with chronic pain. We'll forward the latest information on treatment options as they become avaialable!

 
"All 'personal information' ('personal information' is defined as any information that identifies or can be used to identify, contact, or locate the person to whom such information pertains) that we collect and maintain will be held in confidence by GPP or its direct contractor(s). "

Our Privacy Policy

 

 

 

 

 

 

 

 

 

 

First Name:

Last Name:

e-mail address:

How did you hear about Georgia Pain Physicians?

Referred by a physician (name)

Peer reviewed publications

TV Advertising

Internet Search Engine

Referred by a friend

Are you the patient, or are you researching on behalf of a patient:

Patient Friend or relative of patient

Has the cause of the pain condition been diagnosed by a physician?

Yes No

If yes, please check all that apply:

migraines and cluster headaches

back pain or neck pain

reflex sympathetic dystrophy

failed back surgery syndrome

fibromyalgia

other immune system disorders

vertebroplasty (vertebral compression fracture)

herniated disc

failed discectomy

osteoarthritis

cancer

myofacial pain

complex regional pain syndrome

How long have you suffered with your pain condition?

less than 3 months

3 - 6 months

6 months - 1 year

1 - 3 years

longer than 3 years

Do you feel that you suffer from other symptoms as a result of your pain condition?

depression

insomnia/sleep deprivation

lack of energy

weakened immune system responses

Has your pain condition caused problems in other areas of your life?

work related absences

problems with relationships

inability to manage day-to-day tasks

feeling that you can't cope

Thanks for taking a moment to help us learn more about how pain impacts people's lives.

Would you like to receive a free copy of Dr. Windsor and Dr. Falco's new text, Clinical Orientation to Spinal Anatomy? If you check yes, we'll forward instructions (pick-up at our office for free, or $8.95 shipping and handling - we'll e-mail instructions to address indicated above).

Yes No

Would you like to have a physician or case manager contact regarding your pain condition via e-mail?

Yes No