Name:
*
First Name
Last Name
Date Of Birth:
*
Please click on the calendar icon to select to Date of Birth.
MM
DD
YYYY
Gender:
Mobile:
*
(###)
###
####
Email:
*
Occupation:
Marital Status:
Private
Single
Married
Divorced
Partner
Separated
Widow
Widower
Medical Diagnosis
*
If you have a medical diagnosis, please provide the details. If not, briefly describe the condition you wish to treat and your goals for Stem Cell Therapy.
Who is your Patient Advisor?
*
Please select the name of your PA
Name:
First Name
Last Name
Mobile:
Country
(###)
###
####
E-mail:
Alternative phone number:
Country
(###)
###
####
Do you need assistance walking?
Do you need a wheelchair?
Other needs:
Physician/Primary Care Provider Name:
Contact Number:
(###)
###
####
E-mail:
Primary Disease Diagnosis:
*
Date of Diagnosis:
MM
DD
YYYY
Any relevant past medical history?
*
Anything you take daily medication for.
Prior trauma injuries:
Have you ever been hospitalized or undergone surgery?
*
If yes, please describe below the reason and for how long.
Medical Records Available:
*
Since when?:
MM
DD
YYYY
Explain why?:
Current Medications:
*
Please:
1.- List all of them, including nutritional supplements.
2.- Specify how long have you been taking it, dose and administration route (including hormones, steroids and/or corticosteroids).
Do you have any custom, habit, or tradition you want us to take into account?
Do any of your immediate family members have: Diabetes, Cancer, Hypertension or any other chronic disease?
*
If none of the listed conditions apply, please specify any other medical conditions present in your family history.
Have you ever been diagnosed with any type of cancer?
*
Cancer is one of the main contraindications for Stem Cell Treatments.
Cancer Type:
Date of Diagnosis:
MM
DD
YYYY
Current Cancer Status:
Do you have any history of heart disease?
Please specify (heart attacks, arrythmias, etc).
Do you have any history of gastrointestinal disease?
Please specify.
Ulcers or open wounds anywhere on your body?
Rapid Weight Loss?
Have you had Hepatitis? If so, please describe below which type.
Do you have HIV?
Please specify if it's HIV 1 or HIV 2, and since when (if applicable).
Do you have AIDS?
Please specify since when (if applicable).
Have you experienced any neurological condition such as Stroke, Epilepsy or seizures, Dementia (including Alzheimer's disease), Parkinson disease, Multiple Sclerosis (MS), Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease)?
If yes, please specify the condition, how long you’ve had it, and the date of diagnosis (if known).
Have you ever had any thyroid-related condition, such as Graves’ disease or Hashimoto’s thyroiditis?"
If yes, please specify the condition, how long you’ve had it, and the date of diagnosis (if known).
Have you ever been diagnosed with any of the following conditions: Diabetes (both types), Thyroid disorders (hyperthyroidism and hypothyroidism), Adrenal insufficiency, Cushing's syndrome, Osteoporosis?
If yes, please specify the condition, how long you’ve had it, and the date of diagnosis (if known).
Have you ever been diagnosed with any of the following respiratory conditions: COPD, ARDS, Asthma, Pulmonary Fibrosis, Pneumonia, COVID-19 or any other disease/condition related with your respiratory system?
If yes, please specify the condition, how long you’ve had it, and the date of diagnosis (if known).
Have you ever been diagnosed with any of the following renal conditions: Chronic Kidney Disease (CKD), Acute Kidney Injury (AKI), Glomerular diseases, Polycystic Kidney Disease (PKD), Kidney infections, Kidney stones, Obstructive uropathies, Nephrotic syndrome or Renal cancer?
If yes, please specify the condition, how long you’ve had it, and the date of diagnosis (if known).
Have you ever been diagnosed Syphillis?
If yes, please specify the condition, how long you’ve had it, and the date of diagnosis (if known).
When was your last vaccination?
MM
DD
YYYY
Do you smoke?
*
This includes all tobacco products, cannabis, vaping and e-cigarrette products, other recreational substances.
If you smoke please specify how often, how many and since when.
Do you drink alcohol?
*
If yes, please specify: how much, how often and since when.
Do you take Human Growth Hormone?
If yes, please specify: how much, how often and since when.
PSA Test
(Men Only)
PSA Test Date:
MM
DD
YYYY
PSA Test Result:
Periodic Mammograms:
(Woman Only)
Mammogram Test Date:
MM
DD
YYYY
Do You Have Any Questions or Comments?
Please, include any other important information that could be missing, or include any special request you might have:
