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
*
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
Do you have mobility issues
*
Yes
No
Check the conditions that apply to you:
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 (within the last 6 months) laboratory test results available?
*
Yes (labs taken within the last 6 months)
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 experienced 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 all medications you are currently taking:
Do you have any medication allergies?
Yes
No
Not Sure
Please list all of your medication allergies:
Questions Relevant to Regenerative Therapy
Do you have a history of cancer or tumors?
*
Yes
No
When were you diagnosed? What type of cancer/tumor 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
Employment Status
*
Retired
Disability
Full Time
Part Time
Unemployed
What sort of work/school environment do you have?
*
Sedentary Work
Light-Medium Physical Demand
Travel Often
High Physical Demand
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
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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