Stem Cell » Application Form

Today: : 2008-11-21

Personal Information

Last Name:*
First Name:*
MI:
Marital Status:
Place Of Birth
City :
State/ Province:
Country:
Date of Birth:
Age:
Gender:
Height
Meters/Feet:
cm/Inches:
Weight (kg/ lb)
Home Address
home# and street:
street:
City:
State/ Province:
Country:
Postal Code:
Time Zone:
Phone code - number:*
Fax Number:
Cell / Mobile number:
email Address:*
Current/Previous Occupation
Position:
Company Name:
Address
home# and street:
street:
City:
State/ Province:
Country:
Postal Code:
Phone Number:
email Address:
How did you hear about Stem Cell Biotherapy?
Which One?
Who?
Who?

Additional Information

Medical Information

Primary Physician
Full Name:
Address
home# and street:
street:
City:
State/ Province:
Postal Code:
Country:
Phone Number:
Fax Number:
Cell / Mobile number:
Primary Diagnosis:
Date of Diagnosis:
Other Conditions:
List Current Medication & dosage; including supplements:
Current Symptoms
List all known allergies including medications, foods, etc:
What ambulation aids do you currently use?

Patient History:

List all medication taken within the last six months:
List any other medical illnesses & surgical operations, with dates:
Do you smoke?
Cigarettes/cigars/pipes/other?
How much do you smoke per day?
Do you drink?
Wine/beer/hard liquor/other?
How much do you drink per day?
Have you had stem cell treatment before?
where did you receive this treatment?
When did you receive this treatment?
Who was the physician/provider?
What was the outcome?
What do you hope to achieve from this treatment?
How soon would you like to be treated?

Physical Limitations:

How far can you walk before tiring?
Can you stand independently?
Is your vision affected by your condition?
Are you still able to write?
Are you able to read fine print?
Are your upper limbs/hands affected by your condition?

When traveling, do you have any special needs?
ADA accommodation?
Easy wheelchair access?
Other?
Do you need assistance with Walking
if yes, do you need a wheelchair?
Can you transfer independently?
How do you transfer?
Do you need assistance with Bathing?
Do you need assistance with Dressing?
Do you need assistance with Eating?
Do you need assistance with Getting in & out of bed?
Do you need assistance with Getting in & out of a car?
What social support assistance do you have in place?
How has your condition affected your mood & outlook on life?

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