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Inches

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weight in pounds

*If seeking Joint Repair, please list and explain here.

Example - hips, knees, right elbow etc.

Please choose the condition(s) you currently have. (check all that apply) *

Asthma

Lupus (SLE)

Type 1 Diabetes

Type 2 Diabetes

Psoriasis / Eczema

Parkinson’s Disease

COPD / Emphysema

Rheumatoid Arthritis

Hair Loss or Thinning

Multiple Sclerosis (MS)

Hashimoto’s Thyroiditis

Epstein-Barr Virus (EBV)

Erectile Dysfunction (ED)

Post-Concussion Syndrome

Sensory processing disorder

Lyme Disease & Co Infections

Ocular or Vision Degeneration

Brain Fog / Neuroinflammation

Stroke & Post-Stroke Recovery

Alzheimer’s & Cognitive Decline

Neuropathy (peripheral & diabetic)

ALS (Amyotrophic Lateral Sclerosis)

Post Covid (lung damage, inflammation or scarring)

Long Covid (fatigue, cough, sore throat)

Vaginal Dryness or tissue atrophy

Acute Respiratory Distress Syndrome (ARDS)

Inflammatory Bowel Disease (Crohn’s / UC)

Other or None

Select “Other/None” if your condition is not listed or if the options above do not apply to you.

IF OTHER, ADD HERE! Is there anything else you'd like us to know about your health, goals, condition(s) or concerns you may have?

Please share any additional details that may help us understand your situation better. or none

Please list any medication your currently taking.

NAME | DOSE | FREQUENCY | **** if long list, you may email us at [email protected] **

Have you received Vaccine or Booster Shots? If so, please explain type and year. *

Have you been treated for Cancer in the past 5 years? *

YES

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