Regen BioScience Candidate Pre-Screening Questionnaire

Full Name

First NameLast Name

Date of Birth MM/DD/YY

Weight and Height

Contact Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about Regen BioScience

Referred to us? please give us their name so we can thank them.

If Other, will you give us some details?

Have you ever had an organ transplate?

If yes, please give us the date and any additional information.

Do you have any allergies to medications?

If yes, please list them here...

Do you have any other diagnoses? (Please check all that apply)

What is your A1C?

Indicate the Areas of Concern (Check All that Apply)

On average from 1-10, what is your pain level today?

What is your pain level on your worst day?

Is your range of motion limited?

Does the pain radiate out from the source?

If YES, please explain?

How long have you had this problem?

Were you diagnosed? Please explain:

Describe the pain you're experiencing?

What have you tried to fix the problem? (Check all the apply)

Any other way you have tried fixing the problem not listed above, please list them or explain them here?

Did you feel any relief from these treatments?

If YES, when and where?

Do you have difficulty receiving an IV?

What is your estimated height and weight?

What services are you interested in? (Check all the apply)

If unsure, would you like a recommendation?

When would you like to schedule your treatment for?

Any other specific date and time, if the above selection is not suitable.

Date

Hour MinutesAM/PM Option

Would you like to be notified about promotional services?

Please verify that you are human

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The information, including but not limited to text, graphics, images, and other material on this website, is for informational purposes only. No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider with any questions regarding a medical condition or treatment before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you have read on this website.

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