NanoVi - Structured Case Report Submission Form

Instructions for Completing This Form

This form is intended for practitioners to document client experiences with NanoVi™ devices, including the protocol used and any observed or reported outcomes during the treatment period. Please complete all sections accurately, reflecting the client’s condition before and after treatment. Your submission helps expand the understanding of client responses and potential applications in practice-based settings.

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)

Field of Practice

Other

Section 2: Patient Overview (De-identified)

Client Initials

Age

Gender

Relevant Medical History

Current known Medications:

Short Description of the Case/Complaint(s)

Please list each complaint that the client presented and that was treated with NanoVi. For each one, include: (1) how long the client had the symptom before treatment began, (2) the intensity score before treatment, and (3) the intensity score after the treatment period. Use a scale from 1 to 10, where 1 means very low intensity and 10 means the highest intensity or worst level of discomfort. Example: Headache – for three months – before: 8 – after: 2

How long is the treatment period that you are reporting on?

Are there any assessments results you would like to add?

Section 3: NanoVi™ Treatment Protocol

Which NanoVi™ model did you use?

Pre-Set Protocol Used?

If YES, name/description:

Please provide a brief description of the protocol, including session duration and any other relevant details:

Total Sessions Administered:

How many days per week did you typically use it?

Patient Feedback/Comments:

Section 4: Concurrent Therapies Section

Were any other therapies used alongside NanoVi sessions during this period?

If yes, please specify the type(s) of therapy used (check all that apply):

Additinal notes:

Section 5: Supporting Media (Optional but Encouraged)
Upload before/after photos, x-rays, or video. Annotate films where applicable.

File Upload

Brief explanation of uploaded materials:

Section 6: Consent & Submission

By submitting this form, I confirm that:

This case has been de-identified, and if any identifiable media is included, patient consent has been obtained.
I give permission for this case to be reviewed and considered for inclusion in aggregated reports and educational materials.

Case Submission Form