Shockwave therapy – BodyRejuvenation

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)

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?

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

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

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

Pain-relief and tissue regeneration therapy questionnaire

Part 1: Medical History

Part 2: Lifestyle and Symptoms