Regenerative Medicine Prescreen

Date completed *

How did you hear about us? *

Initial Eligibility Screening

Please complete first. The following questions are required.

1. Do you currently have cancer? *

Yes No

If yes — how long have you had it? (if applicable)

Are you currently receiving treatment? (if applicable)

Yes No

If yes, what type of treatment? (if applicable)

2. Are you pregnant? *

Yes No Not applicable / possibly (please discuss)

Section 1 — Patient Information

Full legal name *

Preferred name (optional)

Date of birth *

Age *

Sex at birth *

Gender identity (optional)

Height *

Weight *

Mobile phone *

Email *

Street address *

City *

State *

Zip code *

Occupation (optional)

Section 2 — Areas of Interest & Goals

Which therapies are you interested in exploring? (Check all that apply.) (optional)

Intranasal / Nose-to-Brain therapy Intravenous (IV) therapy Localized joint / soft-tissue injections Not sure — I would like guidance

Biologics you have discussed or are interested in (optional)

What is your primary goal? (Check all that apply.) (optional)

Neurological / cognitive Orthopedic / joint pain or injury Autoimmune or chronic inflammatory Anti-aging, longevity, wellness Other (describe below)

Describe your main goal in your own words *

Section 3 — Primary Concern

Main condition or symptom you are seeking help with *

When did it begin? *

Getting worse? *

Current pain/symptom severity (0–10) *

If joint/orthopedic, area(s) affected (optional)

Prior treatments tried (medications, injections, PT, surgery, etc.) (optional)

Recent imaging (X-ray, MRI, CT, ultrasound)? (optional)

If yes, type and date (optional)

Section 4 — Neurological & Cognitive History

Complete if interested in nose-to-brain, cognitive, or neurological support. Check any that apply. (optional)

If diagnosed, by whom and when? (optional)

Any nasal/sinus problems (congestion, polyps, prior nasal surgery, loss of smell)? (optional)

Yes No

If yes, describe (optional)

Section 5 — Medical History

Have you ever been diagnosed with any of the following? Check all that apply. (optional)

List any surgeries and approximate dates (optional)

Other significant medical conditions (optional)

Section 6 — Medications, Supplements & Allergies

Current prescription medications (name & dose) (optional)

Over-the-counter medications & supplements (optional)

Drug, food, latex, or environmental allergies (and reaction) *

Section 7 — Lifestyle

Section 8 — Acknowledgment & Consent to Screen

Patient signature (type full name) *

Date *

Print name *

Relationship (if not patient) (optional)

Regenerative Medicine — Patient Prescreen Questionnaire

Initial Eligibility Screening

Section 1 — Patient Information

Section 2 — Areas of Interest & Goals

Section 3 — Primary Concern

Section 4 — Neurological & Cognitive History

Section 5 — Medical History

Section 6 — Medications, Supplements & Allergies

Section 7 — Lifestyle

Section 8 — Acknowledgment & Consent to Screen