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    Aura Regenerative Center

    Multidisciplinary Cellular Therapy Follow-Up (Before & After)

    Patient Information

    Regenerative Treatment Received

    Please select all that apply

    If known, please specify dosages:

    Route / Injection Site(s)

    Please select all that apply

    Primary Focus of Treatment

    Please select all that apply

    BEFORE TREATMENT

    Before Treatment – Self-Assessment

    Please rate the following BEFORE treatment (1 = Very Poor, 5 = Excellent)

    Pain & Function (If Applicable)

    0510
    Selected: 0

    AFTER TREATMENT

    After Treatment – Self-Assessment

    Please rate the following NOW (1 = Very Poor, 5 = Excellent)

    Changes Noted Since Treatment

    Please select all that apply

    Overall Change

    Lifestyle Factors Since Treatment

    Please select all that apply

    Additional Comments

    Follow-Up

    Aura Regenerative Center
    REGENERATIVE CENTER
    Multidisciplinary Cellular Therapy Follow-Up
    BEFORE & AFTER — EDUCATION. TRANSPARENCY. PATIENT-CENTERED CARE.
    Patient Information
    Patient Name
    —
    Date of Birth / Email Address
    —
    Date of Treatment at Aura Regenerative
    —
    Date of Follow-Up
    —
    Regenerative Treatment Received
    PLEASE SELECT ALL THAT APPLY:
    Mesenchymal Stem Cells (MSC – Wharton's Jelly)
    MUSE Cells
    Exosomes
    Route / Injection Site(s)
    PLEASE SELECT ALL THAT APPLY:
    None selected
    Aura Regenerative Center  |  Education. Transparency. Patient-centered care.Page 1 of 4
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    Multidisciplinary Cellular Therapy Follow-Up
    Page 2 of 4
    Primary Focus of Treatment
    PLEASE SELECT ALL THAT APPLY:
    None selected
    Before Treatment
    Before Treatment – Self-Assessment
    PLEASE RATE THE FOLLOWING BEFORE TREATMENT (1 = Very Poor, 5 = Excellent):
    ITEM
    1
    2
    3
    4
    5
    Energy level
    1
    2
    3
    4
    5
    Sleep quality
    1
    2
    3
    4
    5
    Mental Clarity / Cognitive Function
    1
    2
    3
    4
    5
    Mood / emotional well-being
    1
    2
    3
    4
    5
    Physical function / mobility
    1
    2
    3
    4
    5
    Pain level (if applicable)
    1
    2
    3
    4
    5
    Overall wellness
    1
    2
    3
    4
    5
    Pain & Function (If Applicable)
    PAIN LEVEL BEFORE TREATMENT (0 = No Pain, 10 = Worst Pain):
    0
    1
    2
    3
    4
    5
    6
    7
    8
    9
    10
    Selected: 0
    BEFORE TREATMENT, DID YOU EXPERIENCE ANY OF THE FOLLOWING?
    Chronic pain
    Stiffness
    Limited mobility
    Pain during daily activities
    Pain during exercise
    Sleep disturbance due to pain
    Reliance on pain medication
    Not applicable
    Aura Regenerative Center  |  Education. Transparency. Patient-centered care.Page 2 of 4
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    Aura Regenerative Center
    Multidisciplinary Cellular Therapy Follow-Up
    Page 3 of 4
    After Treatment
    After Treatment – Self-Assessment
    PLEASE RATE THE FOLLOWING NOW (1 = Very Poor, 5 = Excellent):
    ITEM
    1
    2
    3
    4
    5
    Energy level
    1
    2
    3
    4
    5
    Sleep quality
    1
    2
    3
    4
    5
    Mental Clarity / Cognitive Function
    1
    2
    3
    4
    5
    Mood / emotional well-being
    1
    2
    3
    4
    5
    Physical function / mobility
    1
    2
    3
    4
    5
    Pain level (if applicable)
    1
    2
    3
    4
    5
    Overall wellness
    1
    2
    3
    4
    5
    Changes Noted Since Treatment
    PLEASE SELECT ALL THAT APPLY:
    Improved energy
    Improved sleep
    Improved mental clarity
    Improved mood
    Reduced pain
    Reduced inflammation or body aches
    Improved mobility / range of motion
    Improved physical recovery
    Improved immune resilience
    Improved overall well-being
    No noticeable changes yet
    Overall Change
    COMPARED TO BEFORE TREATMENT, HOW WOULD YOU DESCRIBE YOUR OVERALL CONDITION NOW?
    Significantly improved
    Moderately improved
    Slightly improved
    No change yet
    Lifestyle Factors Since Treatment
    PLEASE SELECT ALL THAT APPLY:
    None selected
    Aura Regenerative Center  |  Education. Transparency. Patient-centered care.Page 3 of 4
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    Aura Regenerative Center
    Multidisciplinary Cellular Therapy Follow-Up
    Page 4 of 4
    Additional Comments
    PLEASE SHARE ANY OBSERVATIONS, CHANGES, OR FEEDBACK FOR OUR MEDICAL TEAM:
    No additional comments provided.
    Follow-Up
    WOULD YOU LIKE A FOLLOW-UP CONSULTATION WITH OUR MEDICAL TEAM?
    Yes
    Not at this time
    Consent
    I confirm that the information provided above is accurate to the best of my knowledge.
    Patient Signature
    Date
    Aura Regenerative Center
    Aura Regenerative Center
    This document is confidential and intended for medical use only.
    Aura Regenerative Center  |  Education. Transparency. Patient-centered care.Page 4 of 4