Cellular Optimization – BodyRejuvenation

Health Information

Do you have any current health conditions?

Yes
No

Please specify

Are you currently taking any medications?

Yes
No

Please specify

Have you undergone any surgeries in the past two years?

Yes
No

Please specify

Do you have any allergies?

Yes
No

Medications, foods, or other substances

Please specify

How would you rate your overall health on a scale from 1 (poor) to 10 (excellent)?

1 (poor) - 10 (excellent)

Therapy Objectives

What are your primary goals for seeking Cellular Optimization Therapy?

Anti-aging
Pain relief
General wellness
Other

Please specify

Have you tried any of the following therapies before?

Please specify

Please share your experiences

What are your expectations from the therapy?

Lifestyle Information

Describe your typical daily diet

What is your exercise routine?

type, frequency, intensity

Do you use tobacco products, consume alcohol, or use recreational drugs?

Yes
No

Please specify

How many hours of sleep do you get on an average night?

Are you currently involved in any other forms of alternative or complementary medicine practices?

Yes
No

Please specify

Consent and Preferences

Are there specific concerns or questions you would like to discuss during your initial consultation?

Yes
No

Please specify

Please indicate your preference for the consultation

In-person
Online
Phone

Are you interested in proactive healthcare and preventative measures to optimize your health and longevity?

Yes
No

Do you stay active and prioritize healthy lifestyle habits like exercise and nutrition?

Yes
No

Would you be open to exploring evidence-based, cutting-edge therapies for anti-aging and wellness?

Yes
No

Are you comfortable providing recent blood work or participating in a comprehensive health assessment?

Yes
No

Do you believe in a collaborative approach to healthcare, working with medical professionals to achieve your goals?

Yes
No

Enter your zip code

We need to make sure your state allows telehealth.

Name

First

Last

Email

Phone

How did you hear about us?

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Our clinic is located in Hallandale, Florida, are you nearby?

Yes
I can make it
No, but I'm OK with a virtual consultation

If you live far, we do offer virtual consultations