Regenerative Wellness & Stem Cell Therapy Consultation Form
First Name
Your answer
Last Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Address
Your answer
Phone Number
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Email
Your answer
Employed
Employer
Your answer
How many years employed (if employed)
Your answer
Married
Spouse's Name (if applicable)
Your answer
Spouse's phone number (if applicable)
Your answer
Height
Your answer
Weight
Your answer
General Symptoms - Please check all that apply
Dental History
Present Health Condition
Your answer
Please list the issues you are interested in correcting in the order of importance
Your answer
List Approximately how long you have noticed these
Your answer
Name of primary care physician
Your answer
Phone number of primary care physician
Your answer
When were you last seen there
MM
/
DD
/
YYYY
May we send them updates on your treatment/condition
List previous surgeries and year
Your answer
List all allergies/sensitivities to medication, food etc:
Your answer
List reactions to allergies
Your answer
List the prescription drugs you are currently taking
Your answer
Dose
Your answer
How many times daily
List all nutritional supplements (vitamins, herbs, homeopathies, etc.)
Your answer
Dose
Your answer
How many times daily
Please select the type of pain you are experiancing listed below (if any)
Where are you experiencing the pain?
Is there a certain time of the day any these symptoms are better or worse
Your answer
Check all of the things you have used for these problems:
Is your balance/walking ability affected? Please describe:
Your answer
What do you think causes your problem?
Your answer
Please list the Doctors you have seen for these problems, treatment you received
Your answer
Have your symptoms:
List anything that makes your condition worsen
Your answer
List anything that makes your condition better
Your answer
How would you describe the symptoms? Please check all that apply
Is this condition interfering with any of the following?
Do You smoke?
Do you drink
Do you exercise daily
How would you rate your pain levels within the last week
No Pain
Worst Pain Possible
If you had to accept some level of pain after completion of treatment, what would be an acceptable level
No Pain
Worst Pain Possible
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