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Regenexx History Form

Thank you for your interest in Regenexx with Dr. Stiene.

Section 1: Contact Information
First Name*
MI*
Last Name*
Address*
City*
State*
Zip Code*
Email Address*
Primary Phone Number*
Secondary Phone Number
Type of Insurance and Employer if applicable
Group number and Member ID
Primary Care Physician*
Section 2: Medical History
Gender*
Birth Date*
MM slash DD slash YYYY
Age*
Height (Feet, Inches)*
Weight (lbs.)*
Presenting Problem (ie knee pain, hip pain...)*
Please indicate side affected (Right/Left/Bilateral)*
What diagnoses, if any, has your doctor given you?*
Detailed history of injury*
Other types of care you have had for this problem (PT, alternative medicine, supplements, chiropractic, acupuncture, injections, etc…) If you have had injections of any kind, please note the dates of the injections.*
Where is the pain you want treated by this procedure? Please describe location and quality (ie. sharp, dull, achy) of pain. Please be as detailed as possible.*
What does this problem prevent you from doing? Please be as detailed as possible.*
Please list any prior surgeries:*
Other health history: including problems you take medications for, see a doctor for, have had surgery for, that have caused you to be hospitalized, or any history of communicable diseases?:*
Do you or does someone in your family have a history of blood clots?*
What medications do you take. Please list prescription, over the counter medications and any supplements.*
Do you have any allergies to medications, latex or shellfish?*
Activity level-How many hours of strenuous exercise do you get each week (for example weight lifting, running, cardio machines, yoga, skiing, hard biking)*
Section 3: Social History
Hand Dominance*
- Right
- Left
- Ambidextrous
Tobacco Use*
- Current Smoker
- Former Smoker
- Never Smoker
Alcohol Use*
- Yes
- No
Caffeine Use*
- Yes
- No
Occupation*
Employer*

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20+ Convenient Locations

Anderson - Beechmont (Beacon East)
Anderson - Five Mile
Batesville
Crestview Hills
Dayton (Miamisburg)
Erlanger
Fairfield
Finneytown
Fort Thomas
Hyde Park (Cincinnati Sports Club)
Kenwood
Lawrenceburg
Lebanon (Arrow Springs)
Liberty
Mason
Mason (Stadium Complex)
Montgomery
Montgomery - Hand Center
Oxford
South Lebanon (Physical Therapy Only)
Summit Woods (Sharonville)
West Chester
Western Hills (Beacon West)
Wilmington

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