Chronic Pain & Inflammation – BodyRejuvenation

Health and Medical History:

Please describe the nature of your chronic pain or inflammation:

How long have you been experiencing pain and/or inflammation?

Weeks
Months
Years

What treatments have you previously tried for your pain and inflammation?

Are you currently taking any medications?

Yes
No

Please specify

Do you have any allergies or sensitivities to medications or treatments?

Yes
No

Please specify

Interest in Specific Therapies:

Which of these therapies are you particularly interested in trying? Please select all that apply

How familiar are you with these therapies?

Not at all
Somewhat familiar
Very familiar

Goals and Expectations:

What are your primary goals for seeking these therapies?

What are your expectations from the therapy/treatments you are considering?

Availability and Accessibility:

How often are you able to visit a clinic for treatments?

Daily
Weekly
Monthly
Never

Please add any additional comments or concerns you have regarding your chronic pain, inflammation, or the therapies you are interested in.

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

Yes
No

How much do you budget for your wellness each year?

Less than $1000
More 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.

In the last 3–6 months, what’s been the most frustrating part about your health, energy, or appearance? Please be as specific as possible

(numbers on the scale, lab results, clothes that don’t fit, comments from others, photos you didn’t like, etc.).

Can you describe a recent moment when this problem really bothered you or got in the way of your life? What happened, and how did it make you feel?

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