General Questions
This form will allow our medical professionals to make an informed decision about your candidacy for Regenerative Medical Treatment with Balsoma
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Contact Number
*
Format: (000) 000-0000.
Mailing Address
*
What is your date of birth?
*
-
Month
-
Day
Year
Date Picker Icon
What is your gender?
*
Please Select
Male
Female
N/A
Height
*
Weight
*
Employment Status
*
Retired
Disability
Full Time
Part Time
Unemployed
Do you have mobility issues
*
Yes
No
Medical History
What is the main Condition / Disease you are looking to get relief from?
*
How much pain are you in?
*
No Pain
1
2
3
4
5
6
7
8
9
Extreme Pain
10
1 is No Pain, 10 is Extreme Pain
Check the conditions that apply to you or any member of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
None
Other
Check the symptoms that you' re currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
None
Other
Date of last Doctor Visit?
*
-
Month
-
Day
Year
Date Picker Icon
Do you have recent laboratory test results available?
*
Yes
No
What was the date you performed your bloodwork?
-
Month
-
Day
Year
Date Picker Icon
Have you been on Growth Hormone Therapy (HGH) Before?
*
Yes
No
Have you had any organ transplants before?
*
Yes
No
Have you had surgeries before?
*
Yes
No
Please list the type of surgery, the date and result.
Have you had back issues?
*
Yes
No
Please list the type of issue, the date and any ongoing issues.
Are you currently taking any medication?
*
Yes
No
Please list them.
Do you have any medication allergies?
Yes
No
Not Sure
Please list them.
Questions Relevant to Regenerative Therapy
Do you have a history of Cancer or Tumors?
*
Yes
No
When were you diagnosed ? What type of Cancer was it? , How was it treated? What is your remission status?
History of Autoimmune Disorders?
*
Yes
No
Detail any Autoimmune Conditions
History of Chronic Inflammatory Conditions?
*
Yes
No
Detail any Chronic Inflammatory Conditions
History of Neurological Conditions?
*
Yes
No
Detail any Chronic Neurological Conditions
History of Cardiovascular Conditions?
*
Yes
No
Detail any Cardiovascular Events
Have You Experienced Menopause?
*
Yes
No
Are you Pregnant or Breastfeeding
*
Yes
No
Are you Trying to Conceive
Yes
No
Date of Last Menstruation
-
Month
-
Day
Year
Date Picker Icon
Lifestyle
Do you use any kind of tobacco or have you ever used them?
*
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
*
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
What type of diet do you have?
*
Balanced Diet
Vegetarian
Vegan
Keto
American
Special
What sort of physical activity do you have?
*
Sedentary
Lightly Active
Moderately Active
Very Active
What sort of sleep patterns do you have?
*
Less than 6 Hours
6-8 Hours a Night
More than 8 Hours
Insomnia
What are your stress levels?
*
Frequently Stressed
Occasional Anxiety
Chronic Anxiety
Stress Free
What sort of support systems do you have?
*
Family
Social Life
Work Colleagues
Church / Faith-Based Groups
Limited Social Interactions
Isolated
What are some hobbies?
*
Reading / Writing
Arts & Crafts
Playing Musical Instruments
Sports / Outdoor Activities
Watching TV / Streaming
Video Games
Collecting
None
Other
Are you employed?
*
Retired
Full Time
Part Time
Student
What sort of work/school environment do you have?
*
Physically Demanding
From Home
Travel Often
Desk Work
General Concerns
What are you looking to achieve with Stem Cell Therapy? What results do you expect ? What symptoms are you looking to relieve most?
*
Is there anything else we should know about your lifestyle or heath?
*
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