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Schedule an Appointment
Call Us Now
(806) 355-9355
Toggle navigation
Menu
HOME
Start Here
ABOUT
SERVICES
Resources
FAQ
Patient Forms
Livewell Membership
Medical Fitness
Shop
My account
Cart
Checkout
Shipping & Returns
BLOG
CONTACT
Regenerative Therapy Assessment
What is your age?
Younger than 18
18-30
31-50
50-70
71-89
90+
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
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