STEM CELL TREATMENT MEDICAL FORM
Thank you for your interest in Stem Cell Treatments. By completing this form, you join the thousands of enlightened patients combating their illnesses with the greatest medicine known to man.

This information allows us to evaluate your case and determine how best to improve your medical condition. You can attach additional information/documents. The stem cell specialist will discuss options and treatment protocols with you to develop the best medical direction to take your treatment.

By filling out the questionnaire, the respondent certifies that he or she is at least 18 years of age (those younger than 18 must have a parent or guardian fill out the form). Patient or guardian permits us to use the information for the analysis and evaluation of their condition for treatment at our affiliated treatment center. All Patient Questionnaire information will be treated confidentially and will only be viewed by our organization and affiliated treatment center.

CONTACT INFO OF PERSON SUBMITTING THE FORM
NAME OF PERSON SUBMITTING THE PATIENT'S MEDICAL INFORMATION
If different than the patient
Your answer
PHONE NUMBER OF PERSON SUBMITTING THE PATIENT'S MEDICAL INFORMATION
If different than the patient. (Country code, area code, number)
Your answer
EMAIL OF PERSON SUBMITTING THE PATIENT'S MEDICAL INFORMATION
If different than the patient.
Your answer
Patient Information
PATIENT'S NAME *
(First name, Last name)
Your answer
PATIENT'S DATE OF BIRTH - month/day/year *
Your answer
PATIENT'S GENDER *
PATIENT'S WEIGHT *
Approximate in pounds (optional)
Your answer
PATIENT'S HEIGHT *
Approximate in feet and inches (optional)
Your answer
PATIENT'S BLOOD TYPE - Answer as well as you can *
(A, B, AB or O) and RH type (positive or negative)
Your answer
PATIENT'S PRIMARY AILMENT - Be as specific as possible *
(For example: Relaxing-Remitting Multiple Sclerosis instead of Autoimmune or MS)
Your answer
Patient Location
Street Address *
Your answer
City *
Your answer
State/Province/Region *
Your answer
Zip/Postal Code *
Your answer
Country *
Your answer
Phone Number *
Country Code, Area code and number
Your answer
Emergency Contact Information
EMERGENCY CONTACT NAME *
(First Name, Last Name)
Your answer
EMERGENCY CONTACT RELATIONSHIP TO PATIENT *
Your answer
EMERGENCY CONTACT PHONE NUMBER *
Country Code, Area code and number
Your answer
EMERGENCY CONTACT EMAIL
Your answer
GUARDIAN INFORMATION
GUARDIAN'S NAME - If Applicable
Your answer
GUARDIAN'S RELATIONSHIP TO PATIENT
Your answer
GUARDIAN'S CONTACT INFORMATION
Phone or email
Your answer
Medical Information - Current, Primary and Additional
PATIENT'S AREA OF CONCERN? *
Check all that apply. Disease specifics will be addressed in next section.
Required
PATIENT'S CURRENT DISEASE - SPECIFIC DIAGNOSES *
Please supply the correct medical terminology
Your answer
DATE OF DIAGNOSES *
MM
/
DD
/
YYYY
DATE OF DIAGNOSES *
Current Symptoms of Primary Diagnoses *
Your answer
Secondary Diagnoses, Current Injuries, Medical Issues and/or Infections *
Your answer
Medical History
Additional Disease/Injury History and Relevant Family History *
Your answer
Past Surgeries and/or Rehabilitation *
Your answer
Statement about Patient's Current Condition
Your answer
Medical Questions
Does the Patient have Allergies to Medications and/or other Substances *
Describe allergies in "Other"
Required
Communicable Diseases - HIV, Hepatitis, TB, Herpes, Sexually Transmitted DIsease, etc. *
Describe in "Other"
Cancer History *
Please describe any past incidence of cancer including date diagnosed and treatment protocols in "Other"
Required
Hypertension/Hypotension History *
Please describe in "Other"
Required
Patient Bedsore Status *
Please describe size, location and if it is infected in "Other"
Required
Difficulty Breathing or Shortness of Breath *
Please describe in depth in "Other"
Required
Patient is on a Ventilator *
Please describe in depth in "Other"
Required
Patient has had a Tracheotomy *
Please describe in depth in "Other"
Required
Patient Requires Suctioning *
Please describe in depth in "Other"
Required
Patient Requires Oxygen *
Please describe in depth in "Other"
Required
Patient Has Metal Plates, Rods, Screws or Pins *
Please describe in depth in "Other" with Location
Required
Patient Has a Pacemaker *
Please describe in depth in "Other" Including Why and What Type
Required
Patient Has a Continuous Medication Pump *
Please describe in depth in "Other" Including Why and What Type
Required
Patient Has a Feeding Tube *
Please describe in depth in "Other" Including the type of the tube and type of pump used and if it's used for feeding or medication.
Required
Has The Patient Received at Least One Vaccination in the Past Three Months? *
Please describe in depth in "Other" including type of Vaccination(s) and Date(s) Received
Your answer
Additional Medical Files *
Our doctors may require additional information from local hospitals/doctors before issuing a formal acceptance for treatment. In the spaces below, please upload any doctor reports, medical tests, and/or discharge summaries (these include tests confirming the diagnosis) available at this time. Individual file size is limited to 10mb. All files combined are limited to 20mb total. PLEASE NOTE: Large files will need extra time to upload after you click "submit form" at the bottom of this page; do not close the browser window until you receive confirmation that the form submission was successful.
Your answer
Cellular Therapy History/Expectations
Has the Patient Ever Received Cell Therapy *
Required
If Yes, Please Describe *
Please detail when the patient was treated, how many injections the patient received, the price the patient paid, the location of the treatment center, and what the results were of the treatment.
Your answer
Cellular Therapy Expectations *
What results do you hope to attain from this treatment?
Your answer
Additional Information
PATIENT'S SMOKING HABITS *
PATIENT'S DRINKING (Alcohol) HABITS *
PATIENT'S RECREATIONAL DRUG HABITS *
PATIENT'S EXERCISE HABITS *
PATIENT'S DIETARY RESTRICTIONS/PREFERENCES *
Please include your typical dietary information
Your answer
DATE OF DIAGNOSES *
Please write out. Example: September 15, 2010
Your answer
DATE OF FIRST SYMPTOM *
Please write out. Example: September 15, 2010
Your answer
INITIAL SYMPTOMS *
Your answer
CURRENT SYMPTOMS, ADDITIONAL SYMPTOMS, ADDITIONAL CONDITIONS & ILLNESSES *
Please be as specific and detailed as possible
Your answer
LAST BLOOD PRESSURE
If known (optional)
Your answer
LAST VISION TEST RESULTS
If known (optional)
Your answer
PRIMARY CARE PHYSICIAN NAME, PHONE NUMBER & EMAIL ADDRESS *
Your physician may be contacted in order to review your past medical history/test results
Your answer
SPECIALIST NAME, PHONE NUMBER & EMAIL ADDRESS *
Your specialist may be contacted in order to review your past medical history/test results
Your answer
EMERGENCY CONTACT NAME, PHONE NUMBER & EMAIL ADDRESS *
Your answer
PREVIOUS SURGERIES (Detail Causes and Dates) *
Your answer
FEMALE PATIENT
Please check all that apply (Optional)
TREATMENT LOGISTICS
PATIENT'S CAN TRAVEL INTERNATIONALLY? *
Describe the travel limitations if you have any
SPECIAL TRAVEL REQUIREMENTS
PATIENT'S TREATMENT BUDGET *
Treatment prices vary. This information will help us find the most appropriate treatment for your budget.
PATIENT'S DESIRED TREATMENT DATE *
PATIENT'S DESIRED STEM CELL TYPE *
Patient requests one particular stem cell treatment (please specify) or are they open to all sources and variations?
Your answer
Please type patient or guardian's initials in the space provided. *
These initials are a digital signature indicating: 1. The information provided by the respondent is accurate and complete to the best of their knowledge. 2. The Patient and Patient's Guardian agrees to indemnify and hold harmless the Treating Doctor and his staff, organization and consultants of and from any and all claims, demands, losses, causes of action, damage, lawsuits, judgments, including attorneys' fees and costs, arising out of or relating to the work performed by the Treating Doctor and his staff, organization and consultants.
Your answer
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