Treatment Progress

Your results after stem cell therapy treatments are important to us. Please share your progress so we may continue providing the best possible care. Information submitted in this form may be used for educational or marketing purposes, but patients' identities will not be disclosed. Thank you!

First name*

Last name*

Condition(s) Treated*

Neck or Back

Knee

Hip

Shoulder

Elbow

Hand or Wrist

Foot or Ankle

Autoimmune Disorder

Neurological Disorder

Other (please specify)

Treatment(s) Received*

Neck or Back Injection(s)

Joint Injection(s)

IV Infusion(s)

Approximately how many weeks or months ago did you complete treatment?

Average pain PRIOR to treatments (0= none, and 10= the worst)

Average pain AFTER receiving treatments (0= none, and 10= the worst)

Average flexibility/ range of motion PRIOR to treatments. (0= unable to bend or move at all, and 10= no limitation)

Average flexibility/ range of motion AFTER receiving treatments. (0= unable to bend or move at all, and 10= no limitation)

What are some daily tasks, activities or motions that you were unable to, or had difficulty performing, PRIOR to treatments?*

How do you compare the above tasks, activities, or motions AFTER receiving treatments?*

Please rate the improvement you feel overall. (0% = no improvement, and 100%= full recovery)*

Please rate your overall satisfaction with your results. (0% = not satisfied at all, and 100%= completely satisfied)*

Please list and comment on any other symptoms you experienced prior to treatment, compared to the results after receiving treatments.

Please list any other benefits you have noticed AFTER receiving treatments or anything else you would like to add.

Chicago Stem Cell Therapy &

Pain Management Institute

Zaki Anwar, MD

10181 W Lincoln Hwy

Frankfort, IL 60423

New Patients Call: 815-412-6192

Main Office Call or Text: 815-464-7212

Text STEM to 815-464-7212 to learn more

OFFICE HOURS

Monday-Thursday: 9am to 5pm

Friday: 9am to 3pm

Saturday-Sunday: Closed

Link Hub

This website, www.chicagostemcelltherapy.com, offers the opportunity to connect with regenerative medicine and stem cell therapy professionals as part of clinical practice. Because stem cell therapy is not the standard of care in the United States, the following important disclosures are made:

The science of treatment with stem cell therapies can be considered experimental.

The outcome of stem cell therapies will vary between patients and no particular measurement of success can be guaranteed.

There could be unknown risks associated with stem cell therapies as long-term studies have not been performed.

Treatments by licensed providers will only be performed after the patient understands and agrees to informed consent.

The testimonies of people who appear on this website have voiced their experiences at their own free will.

The stem cell therapies performed in this office are not a clinical trial.