Stem Cell Low Back Questionnaire

Your Contact Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone

Preferred Contact Method

My primary pain is lower back and not leg pain or leg numbness*

I have been told I have leg pain or numbness due to a herniated disc or spinal stenosis*

I have been told my back pain is due to mild to moderate degenerative disc disease*

I have been told my back pain is due to very advanced degenerative disc disease*

I have had this condition for over 6 months and tried conservative care*

I have had a MRI or CT of my lumbar spine in the past few years*

I currently have cancer or have a history of a blood type cancer like leukemia or lymphoma*

I understand that this is not covered by insurance*

I am on a blood thinner prescribed by my doctor*