Pain Patch Pain Management Survey – Regenerative Wellness

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PAIN MANAGEMENT | WEEK 1 SURVEY

Please fill out the following form and submit. You should receive a confirmation email. If you do not, please contact our offices right away. Thank you!

- Step 1 of 10

What survey are you submitting? *

Please select the survey that matches the week you are in for your pain patch trial.

HIPPA Consent

I understand that as part of my health care, this practice originates and maintain health records describing my health history, symptoms, examination and test results, treatment, and any plans for future care or treatment. By clicking "I accept" you agree to the terms of the HIPPA Privacy Rule of Patient Authorization Agreement. I also give my permission to release my test results to other healthcare providers.

Do you accept to the HIPPA Consent *

I accept

Informed Consent

Please carefully read and indicate acceptance of the following Informed Consent:

I (or legal guardian for minors) authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a saliva sample or blood sample, as ordered by an authorized medical provider or public health official.

I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others.

I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regard to my test results. I agree that I will seek medical advice and treatment from my medical provider if I have questions or concerns or if my condition worsens.

I understand that, as with any medical test, there is a potential for a false positive or false negative COVID-19 test result.

Release: To the fullest extent permitted by law, I hereby release, discharge and hold harmless, Regenerative Wellness and Predictive Labs, including, without limitation, any of it's respective offices, directors, employees, representatives, and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection than any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results.

I have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed consent. I have been given the opportunity to ask questions before I click Accept, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.

Do you accept the Informed Consent *

I accept
I do not accept

Name *

First

Middle

Last

Person being tested

Phone *

Email *

May use legal guardian's email address for minors

Address *

Address Line 1

Address Line 2

City

State

Zip Code

How old are you? (Age) *

Please enter your current age.

Date of Birth *

Person being tested

Current Marital Status?: *

Gender *

Person being tested

Race *

Ethnicity *

Education Level *

Employment *

What type of pain are you experiencing (diagnosis)? *

For each of the following words, check YES or NO if the word applies to your pain.

Aching *

Yes
No

Throbbing *

Yes
No

Shooting *

Yes
No

Stabbing *

Yes
No

Gnawing *

Yes
No

Sharp *

Yes
No

Tender *

Yes
No

Burning *

Yes
No

Exhausting *

Yes
No

Tiring *

Yes
No

Penetrating *

Yes
No

Nagging *

Yes
No

Numb *

Yes
No

Miserable *

Yes
No

Unbearable *

Yes
No

Brief Pain Inventory

Have you experienced any pain other than minor headaches, sprains, and toothaches? *

Yes
No

Please rate your pain (0-10) that best describes your pain at its WORST in the last 24 hrs.

Selected Value: 0

Please rate your pain (0-10) that best describes your pain at its LEAST in the last 24 hrs.

Selected Value: 0

Please rate your pain (0-10) that best describes your pain at its AVERAGE in the last 24 hrs.

Selected Value: 0

Please rate your pain (0-10) that best describes your pain at its RIGHT NOW in the last 24 hrs.

Selected Value: 0

We are required by the health department to ask the following questions:

Are you pregnant? *

Person being tested

Do you work in healthcare? *

No
Yes

Are you currently hospitalized? *

No
Yes

Have you been in the ICU in the last 30-Days? *

No
Yes

Are you a resident in a care center? *

No
Yes

Do you have any of the following health conditions (Please check all that apply) *

Serious heart conditions
Chronic lung disease
Asthma that is moderate to severe
Diabetes
Obesity (BMI > 40)
Liver Disease
Kidney Disease requiring dialysis
Current cancer treatment
Organ or bone marrow transplant
Sickle cell, thalassemia, or other hemoglobin disease
Taking medications that weaken the immune system (such as steroids)
Deficiencies of the immune system or HIV
None

4698 Highland Dr. Millcreek, Utah 84117
801-797-5901
info@regwellness.co

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