STEM CELL TREATMENT EVALUATION

WEIGHT (in kilograms)

To improve our treatment we kindly ask you to fill this questionnaire

PLEASE GIVE TRUE ANSWERS TO THE QUESTIONS BELOW.

Write appropriate numbers into appropriate spaces or tick YES/NO as necessary.

1. Where on the scale 1-5 was your joint pain?

Scale: 1=almost no pain;2= mild pain;3=medium pain;4=severe pain; 5=pain beyond relief necessitating use of pain relievers

2. What amount of pain relievers or arthritis gel or cream (state the number of applications and administrations) did you have to use?

Scale: 0=no tablet or gel/cream application; 1-40=number of applications of an arthritis cream/gel/tablets

3. Limp. State how much was your walking ability affected by limp?

Scale 0=none ;1=; 2=mild; 3=;medium ;4=quite a lot; 5=substantially-pain made it impossible for me to walk

4. Describe the mobility of affected joint, what were the limitations?

Scale 0=none;1=minimum limitation; 2=mild; 3=medium; 4=substantial;5=virtually no mobility at all

5. Did you feel joint stiffness? If more of you joints had arthritis, describe the most severely diseased one.

Scale 0=no stiffness; 1=minimum; 2=mild; 3=medium; 4=substantially; 5=stiffness excluding mobility

Please complete 6-12 months after treatment

Please complete 6-12 months after treatment. Scale: 0=absolutely yes; 1=yes- more or less; 2=yes-partially; 3=I am not sure; 4=rather not; 5=not at all

Thank you for your time. Your answers will be collected and used for internal procedures leading to improvement of our services. All your personal information will be handled as confidential and will not be published without your authorization. However, we would like to have your kind consent to use the information that you have provided anonymously for scientific and medicinal purposes. A numerical code will be used instead of your name and results might be eventually published in a medicinal or scientific magazine.

* - Items marked are required