by Rick Kaselj
Kinesiologist, Pain & Injury Specialist

YES! You can live pain-free every day.

Awesome! Just 1 More Step…

Please answer these questions so I may better understand your personal situation, background and goals.

Your email address:
What is your gender?
Male
Female

What age group are you in?
I am in my 20's
I am in my 30's
I am in my 40's
I am in my 50's
I am in my 60's
I am in my 70's or older

Are you a health & fitness professional?
Yes
No

What is your main health & fitness goal?
Lose Weight/Fat or Get In Shape
Get Stronger or Build Muscle
Overcoming Current Injuries
Longevity, Safe Training and Energy

What pain or injury do you need help with? (choose one or more):
Neck Pain
Shoulder Pain
Elbow Pain
Wrist & Hand Pain
Back Pain
Hip Pain
Knee Pain
Foot & Ankle Pain

Do you have any health concerns?
Do you have/are you concerned about Diabetes? (CHECK IF APPLIES)
Do you have/are you concerned about Alzheimer’s? (CHECK IF APPLIES)
Do you have/are you concerned about Heart Disease? (CHECK IF APPLIES)
Do you have/are you concerned about Muscle Pain? (CHECK IF APPLIES)
Do you have/are you concerned about Vision Health? (CHECK IF APPLIES)
Do you have/are you concerned about Joint Pain? (CHECK IF APPLIES)

Where do you live?
USA
Canada
Europe
Mexico
Central or South America
Australia or Surrounding Area
Asia or Africa



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