Physicians
Locations
Services
Specialties
Patient info
Careers
News
Contact

(513) 354-3700
Book Online

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

Services
Arthritis Treatment
Alternative Treatments for Musculoskeletal Pain
Platelet Injections
Orthopedic Urgent Care
Orthopedic Clinic
Orthopedic Surgery Centers
Orthopedic Imaging
Physical Therapy
Sports Medicine
Hand Therapy
Joint Replacement
Orthobiologics
Orthopedic Oncology
Physical Medicine & Rehabilitation
Athletic Training
Chiropractic Care
Durable Medical Equipment
Telehealth Video Visits
Concussion Testing
Pain Management

Specialties
Back & Neck Care
Foot & Ankle
Hand & Wrist
Hip Care
Knee Care
Shoulder & Elbow

Book Online
Medical Records
Patient Education
Patient Forms
Patient Portal
Pay Online

About Beacon
Blog
Careers
Contact

Call or
Text 24/7

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*

Questions? Contact Us Call: (513) 354-3700
Call Center Available 24/7

First Name*
Last Name*
Email*
Phone*
Message
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

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

Notice of Privacy Practices

Website Privacy Policy

Beacon Orthopaedics & Sports Medicine, Ltd. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. If you speak a language other than English, language assistance services, free of charge, are available to you. Call the Call Center at (513) 354-3700. Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al Call Center at (513) 354-3700. 繁體中文 (Chinese): 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 Call Center at (513) 354-3700.

Copyright © 2005-2023 Beacon Orthopaedics & Sports Medicine, Ltd. All Rights Reserved. | Sitemap