Where are you currently experiencing pain or discomfort? (Select one)

Knee, shoulder, or hip

Lower back or spine

Neck or upper back

Nerve pain or neuropathy

Multiple areas

Other or unsure

Where is your pain located?

Pain Duration

Less than 3 months

3-12 months

Over 1 Year

Over 5 Years

How long have you had this issue?

Treatments Tried

Pain Medication

Injections (Steroids, etc.)

Surgery or Recommendation

Physical Therapy

Chiropractic

Nothing Yet

What have you tried for relief?

Pain Level - How would you rate your pain?

No Pain

Mild

Moderate

Severe

Unbearable

How would you rate your pain today?

Quality of Life Impact - Has this pain affected your daily life?

Major Impact

Minor Impact

Very Limited or No Impact

Surgery Status - Have you been told you need surgery?

Yes

Not yet, but I'm worried

Openness to Treatment - Are you open to regenerative therapy?

If it will work for me yes

Im curious, but unsure

I'm skeptical

Interest in Avoiding Medications or Surgery - How important is it for you to avoid long-term medications or surgery?

Extremely important — that's my top goal

It matters, but I’m open to other options

I'm willing to do whatever is required

I haven’t really thought about it

Rate Your Willingness to Explore New Treatment Paths

Very open — I’ve done my research

Somewhat open, but I have questions

Hesitant — I’m not sure yet

Impact on Mental or Emotional Health

It's taken a toll on my and my loved ones.

Somewhat - I notice the effects

It hasn't affected me

Full Name *

Email *

Phone

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