Regenerative Health

Patient Questionnaire

Please fill out this form to help us understand your health concerns and create a personalized treatment plan.

Full Name

Date of Birth

Phone Number

Email Address

What is your main reason for seeking care?

For each concern, please describe the symptom and its severity. Severity is a measure of how much this concern affects your daily life.

Area of Symptom/Condition

Severity Level (0-10) 0

Describe the symptom or condition

Do you have difficulty with any of the following activities? (e.g., walking, climbing stairs, standing for long periods, bending, lifting)

Do you participate in any sports or physical activities? If so, which ones and how are they impacted by your symptoms?

On average, how many hours of sleep do you get per night? How would you rate your sleep quality?

Please describe your general dietary habits and water intake.

Do you have any known allergies?

Please list any significant past medical history (e.g., surgeries, diagnoses, hospitalizations).

Please list all current medications, supplements, and dosages.

I acknowledge that the information provided is accurate to the best of my knowledge.