Questionnaire

1. Do you have any other concern or condition you are seeking therapy for other than ...?

2. How long have you experienced this condition or related symptoms?

Less than 3 months 3–12 months 1–3 years Over 3 years

3. Please rate the severity of your symptoms or impact on quality of life (0 = no symptoms, 10 = severe):
0

Please describe:

4. Have you received any previous treatments or interventions?

Yes Please describe: No

5. Are you currently under medical supervision for this issue?

Yes No

6. Do you have any of the following?

Autoimmune disease Allergies to medications or biologics Immune suppression or history of cancer Blood clotting disorders None of the above

Other medical conditions

7. What are your goals for this therapy? (Select all that apply)

8. Are you interested in the following options?

Localized injections IV infusions Topical / external applications Not sure — I’d like guidance

9. Preferred method for consultation/follow-up:

Telemedicine Phone Email

10. When would you like to schedule a consultation?

As soon as possible Within the next month I’m still gathering information

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