Chronic Illness & Inflammation

Health Background

Please specify your diagnosed chronic condition(s) (e.g., Lyme disease, fibromyalgia, chronic fatigue syndrome, chronic inflammation):

How long have you been diagnosed with these conditions?

Symptom Assessment

Please list your primary symptoms and their severity (mild, moderate, severe):

How do these symptoms affect your daily life (e.g., mobility, sleep, work)?

Previous and Current Treatments

What treatments have you tried previously for your condition?

Are you currently under any form of treatment?

Yes
No

Please specify

How effective have you found your current or past treatments?

Very efficiently
Moderately efficiently
Somewhat efficiently
Not efficiently

Interest in Specific Therapies

How familiar are you with the following therapies?

Very familiar
A little familiar
Not familiar

● Extracorporeal Blood Oxygenation and Ozonation (EBOO)

● Ultraviolet Blood Irradiation (UBI)

What are your expectations from these therapies?

Lifestyle

Describe your current diet and exercise routines:

Do you use tobacco or alcohol?

Yes
No

How frequently?

Daily
Occasionally
Rarely

Medical History

Do you have any other medical conditions that might affect or be affected by EBOO/UBI treatments?

Are you currently taking any medications, supplements, or herbal treatments?

Consent and Preferences

How did you hear about our therapies?

Would you be willing to undergo a comprehensive medical evaluation before starting treatment?

Yes
No

What are your preferred days and times for treatment sessions?

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

How much do you budget for your wellness each year?

Less than $1000
Less than $10,000
More than $10,000

We know this question may feel personal—but it's important. It helps us prioritize patients who are committed to long-term results, and tailor recommendations that make sense financially and medically.

Enter your zip code

We need to make sure your state allows telehealth.

Name

First

Last

Email

Phone

How did you hear about us?

Please specify

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