Stem Wave Questionnaire Form

Name:

Date:

Pain Assessment

For all areas where you experience pain, answer the following questions:

1. Describe your pain location(s):

2. How long have you been experiencing this pain?

Less than 1 month 1-3 months 3-6 months 6 months-1year 1-2 years More than 2 years

3. How would you describe the pain? (check all that apply)

Sharp

Dull

Aching

Throbbing

Shooting

Burning

Tingling

Other

4. What was the cause of the pain, if known?

Injury

Overuse

Post-Surgery

Other

5. Have you previously sought treatment for the pain?

Yes No

If yes, please list treatments received (e.g., chiropractic care, physical therapy, surgical interventions, medications, injections)

6. Are you currently taking any medications for this pain?

Yes No

If yes, list medications

Pain Rating Assessment

1. Rate your pain intensity on a scale from 0 to 10:

2. How does the pain affect your daily activities?

Minimal Impact Moderate Impact Severe Impact

Activities most affected (e.g., walking, sitting, sleeping)

3. How often do you experience the pain?

Occasionally (1-2 times per week) Frequently (3-4 times per week) Constantly (daily)

Pain Duration

minutes/hours per episode

StemWave® Treatment Information

1. Knowledge of StemWave®:

a. How did you hear about StemWave® therapy?

b. Have you had StemWave® treatments before? If so, when and for what condition?

2. Goals of treatment:

a. What are your expectations and goals for StemWave® therapy?

RISKS OF PROCEDURE: There may be temporary pain &/or soreness. This typically resolves within hours or 1–2 days.

do hereby consent to authorize the application of today's treatment for the above-stated issues. I fully understand the nature of the treatment or procedure and confirm that I have either researched this treatment option or had it fully explained to me by the treating physician or staff. Upon entering the facility, I was provided the opportunity to discuss and clarify any concerns I may have.

I acknowledge that StemWave® is an elective therapy and that during the initial mapping, relief of symptoms or full resolution of my condition cannot be guaranteed. By choosing this treatment, I am forgoing the opportunity for alternative and/or medical treatments based on my personal discretion. I also recognize that following all aftercare recommendations provided by my healthcare provider is crucial for optimizing results. I have had the opportunity to ask questions about the procedure, all of which have been answered to my satisfaction.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

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