Da Vinci Wellness Centre
Home
Protocol
Resources
Protocol
Learn about our clinic
Blog & Articles
Learn more about stem cells
Patient Reviews
Testimonials & results
Study Database
Peer-reviewed research
FAQ
Frequently asked questions
Pricing
Cost of our study
Apply now
Da Vinci Wellness Centre
Treatment Protocol
FAQ
Resources
Patient Reviews
Patient testimonials and results
Pricing
Learn more about treatment cost
Blog & Research
Learn more about stem cells
Study Database
Peer-reviewed research
Contact
Get in touch with our team
Apply for treatment →
Patient Follow Up Questionnaire
Form completion time: under 5 minutes.
Full name
Which post-treatment interval are you submitting this questionnaire for?
3 month
6 month
9 month
12 month
15 month
18 month
21 month
24 month
Subjective Memory
Please indicate your ability to recall information as of today.
1 = poor
10 = excellent
How would you rate your memory?
1
2
3
4
5
6
7
8
9
10
How is your memory of recent events? (today)
1
2
3
4
5
6
7
8
9
10
How is your memory of past events? (10 years)
1
2
3
4
5
6
7
8
9
10
Overall Health
Please indicate a number that best identifies your response toward each statement.
1 = poor
10 = excellent
Physical fitness
1
2
3
4
5
6
7
8
9
10
Flexibility
1
2
3
4
5
6
7
8
9
10
Energy level
1
2
3
4
5
6
7
8
9
10
Balance
1
2
3
4
5
6
7
8
9
10
Coordination
1
2
3
4
5
6
7
8
9
10
Reaction time
1
2
3
4
5
6
7
8
9
10
Strength
1
2
3
4
5
6
7
8
9
10
Stamina
1
2
3
4
5
6
7
8
9
10
Vision
1
2
3
4
5
6
7
8
9
10
Hearing
1
2
3
4
5
6
7
8
9
10
Libido
1
2
3
4
5
6
7
8
9
10
Sexual function
1
2
3
4
5
6
7
8
9
10
Quality of sleep
1
2
3
4
5
6
7
8
9
10
Ability to concentrate
1
2
3
4
5
6
7
8
9
10
Ability to make decisions
1
2
3
4
5
6
7
8
9
10
Stress level
1
2
3
4
5
6
7
8
9
10
Confidence
1
2
3
4
5
6
7
8
9
10
Motivation
1
2
3
4
5
6
7
8
9
10
Symptom management
1
2
3
4
5
6
7
8
9
10
Daily pain level
1 =Extreme pain
10 = No pain
1
2
3
4
5
6
7
8
9
10
Thickness of hair
1
2
3
4
5
6
7
8
9
10
Please explain any changes or improvements you have noticed
Thank you! Your submission has been received!
Oops! Please make sure to fill out every question.