Patient Candidate Questionnaire – Colorado Stem Cell Center

Please answer the following questions, so we can better determine which of our regenerative health procedures is right for you.

Patient Candidate Questionnaire

Name*
First Last
Phone*
Is phone or email the best way to reach you, and what time of day?*
Email*
Age*
What is the part of the body that you wish to treat?*
Please describe the injury and/or degenerative condition of the body part.*
What are the major problems or symptoms prompting you to contact us?*
Have you had surgery on that body part? If so, when?*
Have you had cortisone injections? If so, how many and when?*
Have you received an X-Ray or MRI in the last six months?*
What is your level of activity?*
Are you generally in good health?*
How did you hear about Colorado Stem Cell Center?*
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