Clinical Intake Form | Start Your Stem Cell Assessment

Clinical Intake Form

Complete all sections as thoroughly as possible. The more detail you provide, the more precisely your physician can assess your case. This form takes approximately 12-15 minutes.

Personal Information

Tell us about yourself

Basic information your physician needs before reviewing your case.

First name *

Last name *

Email *

Phone *

Date of birth *

Biological sex

Height

Weight

City and state / country *

How did you hear about Decima?

Primary Condition

What brings you to Decima?

Select your primary treatment interest. You can describe additional conditions below.

Primary treatment interest *

Spinal disc / back pain

Knee osteoarthritis or injury

Hip degeneration

Shoulder / rotator cuff

GLP-1 drug recovery

Systemic anti-aging / longevity

Hormonal / endocrine

Autoimmune condition

Neurological / cognitive

Sports injury / recovery

Describe your primary condition in your own words *

Be as specific as possible — diagnosis if known, location, severity, what it limits you from doing

Do you have a formal diagnosis from a physician?

Yes — confirmed diagnosis

Suspected but unconfirmed

No formal diagnosis yet

If diagnosed, what is the formal diagnosis?

Symptom History

Your symptoms in detail

The more specifically you can describe your symptoms, the better your physician can assess the likely response to treatment.

How long have you had this condition? *

Less than 3 months — recent onset

3 to 12 months

1 to 3 years

3 to 5 years

More than 5 years — chronic

Current pain or discomfort level *

Rate your average daily experience — not your worst day

No pain 5 Severe

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How does this condition affect your daily life?

Unable to exercise or be active

Difficulty sleeping

Cannot sit or stand for long periods

Affecting my work or career

Taking regular pain medication

Affecting my mood or mental health

Limiting travel or social activities

Have had to reduce professional activity

Is the condition getting better, worse, or staying the same?

Getting worse

Staying the same

Slowly improving

Anything else about your symptoms your physician should know?

Prior Treatments

What have you already tried?

This helps your physician understand your treatment history and what has or hasn't worked for your specific case.

Which of the following have you tried? Select all that apply.

Physical therapy or physiotherapy

Chiropractic care

Cortisone / steroid injections

Hyaluronic acid (gel) injections

PRP (platelet-rich plasma)

Nerve blocks or epidural steroid injections

Surgery on this condition previously

Acupuncture or alternative medicine

Regenerative medicine or stem cells elsewhere

None — this is my first intervention

Have you had surgery for this condition?

No surgery

Yes — one surgery

Yes — multiple surgeries

If you've had surgery, briefly describe what was done and when

Have you tried stem cell therapy before for this condition?

No — first time

Yes — some improvement

Yes — little or no improvement

What has helped most so far? What has not helped at all?

Medical History

Your medical background

This section is critical for safety. Please answer honestly — certain conditions affect eligibility for stem cell therapy.

Why this matters: Active cancer, pregnancy, certain autoimmune flares, and some medications can affect the safety and efficacy of stem cell therapy. Your physician needs this information to determine the right protocol — or to advise against treatment if it is not safe for you.

Do any of the following apply? *

Active cancer or cancer treatment within the past 2 years

Currently pregnant or breastfeeding

On anticoagulant / blood-thinning medication

Severe autoimmune condition currently in active flare

Organ transplant recipient on immunosuppressants

None of the above apply to me

One or more of the items you selected may affect your eligibility. Your physician will review this carefully and contact you to discuss. Please complete the rest of the form.

Significant medical history — select all that apply

Diabetes or insulin resistance

Cardiovascular disease or heart condition

Autoimmune condition (rheumatoid, lupus, MS, etc.)

Thyroid condition

Kidney or liver disease

Neurological condition

History of cancer — in remission

Chronic infection or immune deficiency

None significant

Any allergies — medications, materials, or other?

Anything else in your medical history your physician should be aware of?

Current Medications

What are you currently taking?

Include all prescription medications, over-the-counter supplements, and anything you take regularly.

Are you currently taking any prescription medications?

Yes

OTC / supplements only

List your current medications and supplements

Name, dose, and frequency if known. Include GLP-1 drugs, hormones, NSAIDs, vitamins, anything you take regularly.

Are you on any blood thinners or anticoagulants?

Yes — which ones:

Aspirin only

Lifestyle & Goals

Your life and what you want back

Understanding your lifestyle and goals helps your physician design the most relevant protocol.

How would you describe your activity level currently?

Sedentary — condition limits all activity

Light — walking, no strenuous activity

Moderate — some exercise with limitations

Active — training despite the condition

What was your activity level before this condition?

Recreational — gym, hiking, cycling

Competitive amateur athlete

Professional or elite athlete

Generally active — no formal sport

What do you want to be able to do that this condition is preventing? *

Be specific — this is the single most important thing your physician will use to design your protocol

What is your timeline urgency?

Urgent — need help now

Within 1-3 months

3-6 months — exploring

Smoking status

Non-smoker

Former smoker

Current smoker

Lab Results & Imaging

Share what you have

Not required to submit this form — but any imaging or bloodwork you can share significantly accelerates the physician review process.

Do you have any of the following?

MRI — I have results or images

X-ray — I have results or images

Recent bloodwork — within 6 months

Specialist reports or letters

Nothing available yet

If you have imaging, what did it show?

Upload any relevant files — optional

MRI reports, bloodwork, specialist letters. PDF, JPG, or PNG. Max 20MB per file.

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Click to upload files

MRI reports, X-rays, bloodwork, specialist letters

Key bloodwork values if known

Enter anything you know — leave blank what you don't

CRP (inflammation)

HbA1c

Testosterone (if relevant)

Vitamin D

Logistics & Availability

Planning your treatment

Help us understand your availability and preferences so we can match you with the right location and timing.

Preferred treatment setting

Home visit — you come to me

Hotel — I'm traveling for treatment

Partner clinic — I'll go to a clinic

No preference — whatever is best for my protocol

Are you willing to travel for treatment if needed?

Yes — anywhere

Within the US only

Prefer local only

Approximate budget for treatment

Up to $10,000

$10,000 to $20,000

$20,000 to $40,000

No specific limit — I want the best protocol

Earliest you could start treatment if approved

Immediately — this week

Within 2-4 weeks

1-3 months out

Best way to reach you for the physician callback?

Phone call

Text / WhatsApp

Email first

Best time to reach you

Morning (8am–12pm)

Afternoon (12pm–5pm)

Evening (5pm–8pm)

Anything else you want your physician to know before reviewing your case?

Ready to submit your intake

A board-certified Decima physician will review your complete intake within 24 hours and contact you via your preferred method. This is a genuine medical review — not a screening call, not a sales call.

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Your information is HIPAA-compliant and confidential

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Real physician review — not AI, not a call center

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No payment required at this stage

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You will receive an honest assessment — even if the answer is that stem cell therapy is not right for you

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