Condition-Specific Health Screening

Please provide more details based on your selected condition(s) so we can understand your situation better.

Full Name *

Mobile Number *

Seeking therapy for *

Neurological Disorders (Stroke, Cerebral Palsy, Autism Spectrum Disorder)Bones and Joints (Osteoarthritis, Frozen Shoulder, Tendonitis)DiabetesChronic Kidney Disease (CKD)Respiratory Conditions (Chronic Obstructive Pulmonary Disease)General Wellness and Anti-AgeingOthers

Neurological Disorders

What neurological condition are you experiencing or does your child have? *

Neurological Disorders (Adult)

Can you walk on your own, or do you need a walker, cane, or wheelchair? Do you need help with daily activities like bathing, dressing, or eating? Do you have trouble with your balance or have you had any falls recently? Have you had any surgeries or procedures related to your condition? Are you currently taking any medications for your condition? Are you currently doing any physical therapy, occupational therapy, or other rehabilitation programs? What parts of your body are affected (hand, leg, face, or other areas)? Is it just one side or both?

Neurodevelopmental Disorders (Child)

How old is your child? How was your child’s early development — motor milestones (sitting, crawling, walking)? How would you describe your child’s attention span and focus? Are they currently in any therapy programs (speech therapy, occupational therapy, behavioral therapy)? Do they attend regular school, special education, or are they homeschooled? Are there any behaviors like meltdowns, aggression, or self-harm that are difficult to manage? What areas or aspects of your child would you like to improve from stem cell therapy?

Bones & Joints

Which joint or bone area is affected? *

Knee Issues

How long have you been experiencing knee pain or discomfort? Is the pain in one or both knees? Do you feel pain when walking, climbing stairs, or standing up? Have you experienced swelling, stiffness, or grinding sounds in the knee? Has a doctor diagnosed you with arthritis, ligament injury, or cartilage damage? Have you tried treatments like physiotherapy, injections, or medication before? How would you describe your current mobility?

Hip Issues

How long have you been having hip pain or stiffness? Is the pain constant, or does it occur when walking or sitting? Does the pain spread to your lower back or legs? Has a doctor diagnosed you with osteoarthritis or hip degeneration? Have you received any physiotherapy or injections in the hip area? Have you undergone hip surgery or been advised to do so? Are you currently taking painkillers or anti-inflammatory medications?

Shoulder Issues

How long have you had shoulder pain or limited movement? Did the issue start after an injury or gradually over time? Is the pain worse when lifting your arm or rotating it? Has a doctor mentioned rotator cuff injury, tendonitis, or arthritis? Have you tried physiotherapy, injections, or medication before? Does the pain affect your ability to sleep or do daily tasks? Do you experience weakness, numbness, or reduced arm strength?

Spine / Back Issues

How long have you had back or spine issues? Is the pain localized or does it radiate to your legs or arms? Has a doctor diagnosed you with a specific condition? Do you experience numbness, tingling, or weakness in your limbs? Does the pain worsen when standing or sitting for long periods? How would you rate your pain level on a scale of 1–10?

Other Joint / Bone Issues

Which specific joint or bone area is affected? How long have you had this issue? Was it caused by injury or wear and tear? Has a doctor diagnosed the cause? Have you tried any previous treatments like medication, physiotherapy, or injections? How severe is your pain or movement limitation right now? Does it affect your work or daily routine?

Diabetes

What type of diabetes do you have? * When were you diagnosed? * How do you currently manage your diabetes? * What medications are you currently taking? * Do you know your latest blood sugar or HbA1c? * Do you have any other health conditions? *

Chronic Kidney Disease (CKD)

Please note: We are currently unable to accept patients diagnosed with Stage 5 Chronic Kidney Disease for stem cell therapy.

What stage of Chronic Kidney Disease (CKD) have you been diagnosed with? * What are your latest kidney function test results? What is the primary known cause of your CKD? *

Please specify the cause:

When were you first diagnosed with CKD? * How is your CKD currently being managed? (Select all that apply) * Diet ModificationMedicationsRegular Nephrologist Follow-upOther

Please specify other management:

Are you currently undergoing dialysis? * YesNo

What type of dialysis are you receiving? *

Please specify dialysis type:

How often do you undergo dialysis? *

What symptoms are you currently experiencing related to your CKD? Do you have any other diagnosed chronic medical conditions? * Have you previously undergone stem cell therapy or exosome therapy? * YesNo

Please specify when:

Respiratory Conditions

What respiratory condition do you have? * When were you first diagnosed? * Are you currently using any inhalers or oxygen support? * How often do you experience shortness of breath? * Do you smoke or have a history of smoking? * Do you have other health conditions like heart problems or diabetes? *

General Wellness & Anti-Ageing

What are your main goals for wellness or rejuvenation? * Improve energyImprove skinBoost immunityPromote longevity Do you have any known health conditions? (Yes / No — please specify) * Are you currently taking any supplements or medications? * How would you describe your current lifestyle? * Do you smoke, drink alcohol, or have irregular sleep patterns? * Are there any chronic conditions in your family history? * Have you done any wellness or regenerative treatments before? *

Other Conditions

How can we help you today? *

Health Concern / Stem Cell Therapy Interest

Could you briefly describe your condition or symptoms? When did this condition start? Has a doctor provided any diagnosis? Are you currently on any treatment or medication? Have you had any tests, scans, or reports done? What are your expectations from stem cell therapy?

Business / Collaboration Interest

Are you inquiring for business collaboration, investment, or partnership? Could you describe your area of interest? Are you currently involved in the healthcare or biotech field? Where are you based? How did you hear about us? What kind of collaboration are you exploring? Are you representing a company or yourself?