Curonix Candidate Assessment

Contact Information:

First Name

Last Name

Phone

City

State

Country

I am completing this candidate assessment for?

Myself A friend or family member

Please select you or your friend/family member's gender

Male Female

How long have you or your friend/family member been suffering from pain?

Less than 6 months 6 to 12 months More than 12 months

What type of pain is being experienced? (Select all that apply):

Rate the average daily pain level over the past 30 days.

Mild Moderate Extreme

Which pain treatments have you or your friend/family member tried? (select all that apply)

Does pain keep you or your friend/family member from? (select all that apply):

Which statement best describes you or your friend/family member best?