Neurological Regeneration Therapy

Medical History

Primary Diagnosis:

Alzheimer's Disease
Dementia
Parkinson's Disease
Other

Please specify

Date of Diagnosis

Current Stage of the Disease:

Early
Moderate
Advanced

Please list any other medical conditions you have:

Do you have a family history of neurological disorders?

Yes
No

Please specify

Have you undergone any previous treatments for your condition?

Yes
No

Please specify

Current Medications

Please list all medications you are currently taking:

Are you currently participating in any other clinical trials or therapies?

Yes
No

Please provide details

Lifestyle and Symptoms

Describe your current symptoms:

How do these symptoms impact your daily life?

What activities do you find most challenging due to your condition?

Do you follow any specific diet or exercise regimen?

Yes
No

Please provide details

Expectations and Goals

What are your primary goals in seeking neurological regeneration therapy?

What improvements are you hoping to see from the therapy?

Have you consulted with your primary healthcare provider about this therapy?

Yes
No

What was their opinion

Additional Information

Are you willing to travel for the therapy if necessary?

Yes
No

Do you have any questions or concerns about the therapy?

Is there any other information you would like to provide that you think might be relevant?

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
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