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Shockwave therapy
Pain-relief and tissue regeneration therapy questionnaire
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Part 1: Medical History
Are you currently experiencing any of the following conditions? (Please tick as appropriate)
*
Nagging aches and pains (i.e. lower back pain)
Sports injury
Erectile Dysfunction
Other (please specify)
Specify your conditions
*
How long have you been experiencing your condition(s)?
*
Less than a month
1-6 months
More than 6 months
Have you received any previous treatments for your condition(s)?
*
Yes
No
Please specify.
*
Do you have a history of any of the following medical conditions? (Please tick as appropriate)
*
Heart disease
Diabetes
Blood clotting disorders
Cancer
Other significant health conditions
Please specify
*
Are you currently taking any medications?
*
Yes
No
Please list them
*
Part 2: Lifestyle and Symptoms
On a scale of 1 to 10, how would you rate your pain or discomfort on average?
*
10
8-9
6-7
4-5
2-3
1
1 being the least and 10 being the most severe
Does your condition(s) affect your daily activities or lifestyle?
*
Yes
No
Please describe how
*
Have you noticed anything that worsens your symptoms?
*
Yes
No
e.g., specific activities, time of day
What are your expectations from Shockwave therapy?
*
Pain relief
Improvement in mobility
Treatment of Erectile Dysfunction without medication
Have you tried other treatments for ED?
*
Yes
No
what were they and what was your experience?
*
How much do you budget for your wellness each year?
*
Less than $1000
Less than $10,000
More than $10,000
Enter your zip code
*
We need to make sure your state allows telehealth.
Name
*
First
Last
Email
*
Phone
How did you hear about us?
*
Facebook
Instagram
Ad on Google
Google Search
Other
Please specify
*
If you heard about us from another source, 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
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