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Regenerative Therapy Assessment

The following questions concern the amount of pain you are currently experiencing in your knees, For each situation, Please enter the amount of pain you have experienced in the past 48 hours.

	None	Mild	Moderate	Severe	Extreme
A. Walking on a flat surface
B. Going up or down stairs
C. At night while in bed
D. Sitting or lying
E. Standing upright

How severe is your stiffness after first awakening in the morning?

None

Mild

Moderate

Severe

Extreme

How severe is your stiffness after sitting, lying, or resting later in the day?

None

Mild

Moderate

Severe

Extreme

The following questions concern your physical functions. By this we means your ability to move around and to look after yourself. For each of the following activities, Please indicate the degree of difficulty you have experienced in the last 48 hours, in your knees.

What degree of difficulty do you have with:	None	Mild	Moderate	Severe	Extreme
A. Descending (going down) stairs
B. Ascending (going down) stairs
C. Rising from sitting
D. Standing
E. Bending to floor
F. Walking on a flat surface
G. Getting in/out of car
H. Going shopping
I. Putting on socks/stockings
J. Rising from bed
K. Taking off socks/stockings
L. Lying in bed
M. Getting in/out of bath
N. Sitting
O. Getting on/off toile
P. Heavy domestic duties (mowing the lawn, lifting heavy grocery bags)
Q. Light domestic duties (such as tidying a room, dusting, cooking)

Unfortunately at this time regenerative procedures are not covered by insurance. Luckily, we have many regenerative procedure options at our clinic that vary in cost that can make these incredible procedures affordable to everyone. For us to best guide you in a treatment, how much are you willing and able to pay to invest in your health and the chance to be pain free?

< 100

100-300

500-1000

> 3500

Are you interested in participating in our stem cell research trial?

No

Yes

Have you been diagnosed with an inflammatory, autoimmune (like rheumatoid arthritis (RA) or Ankylosing Spondylitis), or degeneration of your musculoskeletal system like osteoarthritis, degenerative joint disease, or tendonitis/tendonosis?

No

Yes

Is your body fat percentage at least 15% (Are you able to pinch about 1 inch of fat somewhere on your body)

No

Yes

Do you have known active cancer and receiving chemotherapy or radiation therapy?

No

Yes

Are you currently on more than the equivalent of 10 mg of prednisone, or received a steroid shot within the last six months?

No

Yes

Do you have any history of opiate addiction or in a treatment program for withdrawal?

No

Yes

Do you have a history of a severe traumatic brain injury?

No

Yes