Pre-screening Questionnaire
First Name
*
Last Name
*
Email
*
Phone Number
*
Date of birth
*
What's your age?
Address
*
State
*
City
*
Postal code
*
Primary Reason for Seeking Stem Cell Treatment
Have you ever had an organ transplant?
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Yes
No
Are you taking any anti-rejection medications?
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Yes
No
Do you have any allergies to medications?
*
Are you taking any blood thinners or anti-inflammatory medications?
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Yes
No
Please list any medications you’re taking below
On a scale from 1 to 10, what is your average pain?
*
Do you have any of the following diagnoses?
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Heart Disease
Active Gout Infection
Active Cancer
Multiple Sclerosis
Ankylosing Spondylosis
Pregnancy
Kidney Disease
Diabetes
Rheumatoid Arthritis
Lupus
Amyotrophic Lateral Sclerosis (ALS)
None of These Apply
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List is empty.
What have you done to fix the problem?
*
NSAIDS
CBD
Chiropractic
Acupuncture
Surgery
Narcotic Pain Meds
Cortisone/Steroid Injections
Massage
Physical Therapy
Epidural
Ablation
Other
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Did any of the above therapies provide relief?
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Is your range of motion limited?
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Yes
No
Does the pain radiate down any extremity?
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How long have you had this problem?
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If you have seen a physician, what was the diagnosis?
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Do you see a pain management specialist?
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Yes
No
If you have had surgery, when? Which areas?:
Do you have difficulty having labs drawn or receiving an IV?
Yes
No
Height
Weight
Any additional notes for PreScreen