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Veteran Stem - My Profile Self-Assessment

This self-assessment form will help you and your doctor create a treatment plan that's right for your needs. Please complete this form and bring it to your consultation.

1. Pain Rating (0 = No Pain, 10 = Worst Possible)

0 1 2 3 4 5 6 7 8 9 10

2. How Does Your Joint Pain Affect Your Life?

Getting in/out of bed or a chair Walking or standing for long periods Using stairs Sleeping comfortably Attending social events Performing work duties Participating in hobbies or sports Feeling confident or mobile

3. Treatments You’ve Already Tried

Over-the-counter pain relief (e.g., Panadol, Nurofen) Physical therapy or exercise rehab Cortisone or gel injections Plasma Rich Protein (PRP) Bone Marrow Aspirate Bracing or support devices Stretching, yoga, or heat/cold therapy

4. Medical Info

I am taking blood thinners I have a bleeding disorder I have allergies to Lidocaine or local anaesthetics I am breastfeeding or plan to soon I am concerned about pain or side effects from medication

5. Your Personal Goals

Short-term goals: Long-term goals:

6. Questions to Ask Your Doctor

Is LIPO-STEM DUO™ suitable for me? What are the expected results? How painful is the procedure? How long is the recovery period? What are the risks or side effects? When can I return to normal activities? Other questions:

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Veteran Stem

Veteran-led regenerative treatments for a stronger, pain-free future.

Email: hello@veteranstem.com
Ph. No: 0416-134-764

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