RheeGen - Structured Case Report Submission Form

Structured Case Report Submission Form
Instructions for Completing This Form
This form is designed to accommodate different treatment durations. Please read the instructions below carefully before proceeding:
- If you are reporting on the results of a 30-day treatment cycle only, please complete Sections 4 and 5, which refer to the treatment protocol and its post-treatment outcomes.
- If the case includes additional treatment cycles (i.e., more than one month of treatment), please complete Sections 6 and 7 instead, which refer to the extended treatment protocol and its post-treatment outcomes.
- All other sections of the form can and should be completed regardless of the treatment duration.
- Please ensure responses reflect the participant’s condition and outcomes after the full treatment period being reported.
Section 1: Practitioner Info
Name

First NameLast Name
Email
example@example.com
Clinic Name
Clinic Website (If you wish we add that information to the Case Report)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
City, State, Country
Field of practice
Credentials
Section 2: Patient Overview (De-identified)
Patient ID Code (e.g., "Patient001")
Date of Birth

MonthDayYear
Date
Gender
Patient background (optional)
Chief complaint
Short description of the Chief complaint
Duration of symptoms
Section 3: Clinical Baseline Assessment

Section A – BEFORE RheeGen Therapy

Select a score from 0 to 10 based on your assessment, where 0 indicates the worst possible status and 10 indicates the best.
Date assessment was performed

MonthDayYear
Date
Pain Intensity: How would you rate the patient’s pain?

0

1

2

3

4

5

6

7

8

9

10

0 is No pain, 10 is Worst imaginable pain
Range of Motion Limitation: How restricted was the patient's movement in the affected area?

0

1

2

3

4

5

6

7

8

9

10

0 is Full ROM, 10 is Completely immobile
Impact on Daily Activities (ADLs): How much was the pain or condition affect daily living and functioning?

0

1

2

3

4

5

6

7

8

9

10

0 is No impact, 10 is Unable to perform ADLs
Emotional Distress Related to Condition:

0

1

2

3

4

5

6

7

8

9

10

0 is Not distressing, 10 is Extreme emotional burden
Sleep Quality Impact (if relevant): How much was sleep disrupted by pain or discomfort?

0

1

2

3

4

5

6

7

8

9

10

0 is No impact, 10 is Unable to sleep without assistance
Are there any assessments results you would like to add?
Diagnosis:
Section 4: RheeGen Treatment Protocol (30-Day Cycle Only)
Date of first application

MonthDayYear
Date
Frequency of application
Applied areas:
Notes on patient tolerance or reaction:
Section 5: Post treatment evaluation (For 30-Day Cycle Only)

Section B – 30 days AFTER RheeGen Therapy

Complete this section only if the participant completed a single 30-day RheeGen treatment cycle. Responses should reflect the participant’s condition and outcomes after completing the full 30-day protocol, not during treatment.

Select a score from 0 to 10 based on your assessment, where 0 indicates the worst possible status and 10 indicates the best.
Date assessment was performed

MonthDayYear
Date
Pain Intensity: How would you rate the patient’s pain?

0

1

2

3

4

5

6

7

8

9

10

0 is No pain, 10 is Worst imaginable pain
Range of Motion Improvement: How restricted is the ROM now in the affected area?

0

1

2

3

4

5

6

7

8

9

10

0 is Full ROM, 10 is Still completely immobile
Impact on Daily Activities (ADLs): How much is the pain or condition affecting daily living and functioning?

0

1

2

3

4

5

6

7

8

9

10

0 is No limitation, 10 is Unable to perform ADLs
Emotional Distress (Post-treatment):

0

1

2

3

4

5

6

7

8

9

10

0 is No distress, 10 is Extremely distressing still
Sleep Quality (if applicable):

0

1

2

3

4

5

6

7

8

9

10

0 is Perfect sleep, 10 is Still unable to sleep without assistance
Are there any assessments results you would like to add?
Section 6: RheeGen Treatment Protocol (Additional Treatment Cycles)

Complete this section only if the participant underwent treatment for over 30 days.
Date of first application

MonthDayYear
Date
Frequency of application
How many treatment cycles (in months) were completed?
Applied areas:
Notes on patient tolerance or reaction:
Section 7: Post treatment evaluation

Section B – AFTER RheeGen Therapy

Complete this section only if the participant received more than one treatment cycle, and only after the full treatment period has been completed. Responses should reflect the participant’s condition and outcomes following the total duration of treatment as described in Section 6.

Select a score from 0 to 10 based on your assessment, where 0 indicates the worst possible status and 10 indicates the best.
Date assessment was performed

MonthDayYear
Date
Pain Intensity: How would you rate the patient’s pain?

0

1

2

3

4

5

6

7

8

9

10

0 is No pain, 10 is Worst imaginable pain
Range of Motion Improvement: How restricted is the ROM now in the affected area?

0

1

2

3

4

5

6

7

8

9

10

0 is Full ROM, 10 is Still completely immobile
Impact on Daily Activities (ADLs): How much is the pain or condition affecting daily living and functioning?

0

1

2

3

4

5

6

7

8

9

10

0 is No limitation, 10 is Unable to perform ADLs
Emotional Distress (Post-treatment):

0

1

2

3

4

5

6

7

8

9

10

0 is No distress, 10 is Extremely distressing still
Sleep Quality (if applicable):

0

1

2

3

4

5

6

7

8

9

10

0 is Perfect sleep, 10 is Still unable to sleep without assistance
Are there any assessments results you would like to add?
Section 8: Concurrent Therapies Section
Were any other therapies used alongside RheeGen during this period?
If yes, please specify the type(s) of therapy used (check all that apply):

Other
Frequency of Each Therapy Comments (e.g., started mid-treatment, stopped early, etc.)
Additinal notes:
Section 9: Supporting Media (Optional but Encouraged)
Upload before/after photos, x-rays, or video. Annotate films where applicable.
File Upload

Cancelof
Brief explanation of uploaded materials:
Section 10: Conclusion
List any objective findings and provide feedback on whether RheeGen was a positive or negative experience. Would you use RheeGen again?
Section 11: Consent & Submission
- I confirm that this case is de-identified and submitted with patient consent if identifiable media is included.
- I give permission for this case to be reviewed and considered for inclusion in aggregated reports and educational materials.
Signature (typed)
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