What areas of your life are affected by the pain? Choose all options that apply.
Household chores
Mobilization
Sleeping
Physical well-being
Emotional health
Exercising
Other
Where is the source of your pain? Choose all options that apply.
Knee
Hip
Shoulder
Elbow
Spine
Ankle
Foot
Hand
Wrist
Which side is more symptomatic?
Both
Left
Right
On a scale of 1-10, one being hardly any pain and ten being unbearable, how would you rate your pain?
1
2
3
4
5
6
7
8
9
10
How did the pain begin? Choose all options that apply.
Came on gradually
Sports related
It just began
Vehicle accident
After surgery
Accident at work/work related
Other
Have you been diagnosed with a bone-on-bone condition?
Yes
No
Have you had any surgeries to your existing pain or any other pain condition?
Yes
No
Do you have any recent MRI or X-ray of the problem area?
Yes
No
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Sex
Male
Female
Prefer not to say
Age
If you are considered to be a good candidate for our Joint Rejuvenation Therapy, how soon are you looking to receive therapy to decrease pain and restore function to your joint(s)?
As soon as possible
Next 1-3 Months
Next 3-6 Months
After 6 Months
PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: I understand that insurance companies and Medicare do not cover joint rejuvenation therapies. Currently, it is viewed as a treatment "above" standard medically necessary care.
Yes
No
First Name
*
Last Name
*
Phone
*
Email
*
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