Stem Cell Research Project Participant Questionnaire Name* First Last Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Best Phone Number*Phone Type* Cell Home Work EmailBy entering your email address you consent to us contacting you by email. Enter Email Confirm Email Are you a Canadian resident? Yes No Are you between the age of 19-79? Yes No Do you have osteoarthritis in a major joint? Please select a maximum of 2 joints:* Left Ankle Right Ankle Left Elbow Right Elbow Left Hip Right Hip Left Knee Right Knee Left Shoulder Right Shoulder Left Wrist Right Wrist You will be randomized into one of 3 treatment groups containing active stem cells from either your lipoaspirate (fat), bone marrow or both. THERE IS NO PLACEBO GROUP. Yes I understand No I do not understand The study involves 3 treatment visits 4 weeks apart to our Kelowna office (travel costs are the responsibility of the participant) Yes, I understand No, I am unable to make that commitment In the absence of corporate sponsorship, the total cost to the participant for all 3 treatments is $7900. Yes, I understand Yes, I understand and would like to receive information about third party financing options No, I am unable to make this financial commitment Please select if you have any of the following:* Severe obesity Extreme end-stage arthritis Active cancer Pregnancy (currently pregnant or plans to become pregnant) Crohn's or Ulcerative Colitis Lupus Rheumatoid Arthritis Psoriasis Active infection or fever Using blood thinners Surgery or Arthroscopy to the affected joint Cortisone or hyaluronic acid injection to the affected joint PRP injection to the affected joint None of the above Surgery or Arthroscopy approximate date: Cortisone or hyaluronic acid injection approximate date: Do you have any allergies to any of the following medications:* Lidocaine Heparin Epinephrine None of the above Do you have any allergies to any other medications? If yes, please list below.Are you currently taking any of the following medications:* Aspirin/ASA Advil/Ibuprofen Aleve/Naproxen Warfarin/Coumadin or other blood thinner Birth Control (pill, injection, IUD) None of the above Are you currently taking any other medications? If yes, please list below.Are you currently taking any of the following supplements: Curcumin/Tumeric Omega 3 Fish Oils Willowbark Boswellia None of the above Family Physician Name The city where your Family Physician's practice is located
