Are you currently receiving cell therapy at OmniStem?

This helps us understand whether the sessions are part of a regenerative protocol or an independent consultation.

Your contact information

This information helps our healthcare team contact you and find your medical records.

What is your date of birth?

Were you referred by an OmniStem physician?

Select the option that best describes how you came to this consultation.

What is your main physical therapy goal?

Select the option that best describes what you hope to achieve.

Confirmed diagnosis or main reason for this consultation.

Enter the diagnosis or condition as stated by your physician. If there is no formal diagnosis, describe your main concern.

How long have you been experiencing this condition?

Select the range that best applies.

Do you have imaging studies available?

X-rays, MRI, ultrasound, or CT scan of the area to be treated.

Can you walk independently?

This helps us prepare the appropriate setup for your first session.

Where do you feel pain or discomfort?

Select all areas that apply. You may choose more than one.

Rate your current pain level

1 = no pain · 10 = most intense pain. If you have multiple areas, rate the area that limits you the most.

How would you describe the pattern of your pain?

Select the option that best reflects your experience.

What relieves your pain, and what makes it worse?

Describe both if applicable. Examples: rest, heat, cold, movement, medication, position.

Are you currently experiencing any of the following symptoms?

Select all that apply.

Are you experiencing any sensory changes?

Select all that currently apply.

Are you experiencing any motor changes?

Select all that currently apply.

Getting up from a chair

Select the option that best describes your current ability.

Subir escaleras

Select the option that best describes your current ability.

Assistive devices you currently use

Select all that apply.

Have you previously received physical therapy for this condition?

Select the option that best describes your experience.

What is the main goal you would like to achieve?

Describe in your own words what a successful outcome would look like for you.

What is your expected timeline for recovery?

There is no wrong answer, this helps align the treatment plan with your expectations.

How do you feel emotionally about your condition?

Select the option that best reflects your current state.

Is there anything else your physical therapist should know?

Optional. Any additional context that may help prepare your evaluation.