Candidate Pre-Screening Questionnaire

Please fill in all fields to the best of your ability.

Full Name *

Phone *

Email *

Address

Street Address

City

State

Country

Postal code

Date of birth *

Height *

Weight *

Do you have any allergies to medications? *

If yes, please list them here *

Have you ever had an organ transplant? *

If yes, please give us the date and any additional information *

What is your A1C? *

Indicate the Areas of Concern (Select All that Apply) *

On average from 1-10, what is your pain level today? *

What is your pain level on your worst day? *

Is your range of motion limited? *

Does the pain radiate out from the source? *

If YES, please explain?

Describe the pain you're experiencing? *

Were you diagnosed? Please explain: *

If unsure, would you like a recommendation?

Do you have any other diagnoses? (Please select all that apply)

What have you tried to fix the problem? (Select all that apply) *

Have you tried fixing the problem using a method not listed above? *

Did you feel any relief from those treatments you listed? *

If YES, when and where?

Do you have difficulty receiving an IV? *

When would you like to schedule your treatment for?

Signature *