Harbor Comprehensive Health
Prospective Client Questionnaire
Basic Information
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Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
- State -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Select your age range
25-34
35-44
45-54
55-64
65+
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1. Are the following body areas painful to you?
Joint Arthritis
Yes
No
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Wrist or Hand
Yes
No
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Elbow
Yes
No
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Knee
Yes
No
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Ankle or Foot
Yes
No
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Back or Hip
Yes
No
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Shoulder
Yes
No
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How long has this pain been going on?
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2. Has a medical professional told you that you need one of the following:
Shoulder Replacement
Yes
No
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Hip Replacement
Yes
No
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Knee Replacement
Yes
No
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3. Are you currently working?
Yes
No
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Do you get most of your pain before, during or after work?
Yes
No
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[{"field":"currently_working","logic":"equal","value":"yes","and_method":"","field_and":"","logic_and":"","value_and":""}]
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[{"field":"currently_working","logic":"equal","value":"yes","and_method":"","field_and":"","logic_and":"","value_and":""}]
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4. Have you received a stem cell treatment before?
Yes
No
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[{"field":"prior_sc","logic":"equal","value":"yes","and_method":"","field_and":"","logic_and":"","value_and":""}]
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5. What interests you most about Stem Cell Regenerative Treatments?
Regenerative Capabilities
Avoiding Surgery
Replacing/Repairing Damaged Tissues
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Submit