1. Have you had a recent injury? 
(explain)

2. When did your pain start?

3. What makes it worse?

4. What makes it better?

5. What have you done to treat it?  Have you had a recent surgery?

6. Do you have images from a previous MRI, ultrasound or Xray?

7. Have you ever heard of or considered non-invasive regenerative medicine?

8. Your pain is:

9. How many hours per day are you in pain?

10. At its worst, how bad is your pain (1-10)?

11. At its best, what is the level of your pain (1-10)?

12. What pain medications or non-prescription remedies have you taken today for your pain?

First Name and Last Initial

Email

Phone