Patient Evaluation Form
(Regenerative)

    1. Patient Information

    2. Parent Guardian Information(For Patients under 18yrs of age)

    3. Treatment RequirementsPlease confirm you have read and understand the requirements below to receive treatment:

    I understand this is a Patient Funded Treatment

    This is a patient funded treatment and unfortunately cannot be covered by any insurance providers, which will require the patient to pay for the cost of the treatment. The cost will vary depending on the type of treatment, patient’s condition(s) and delivery method needed.

    I am able and willing to travel to StemCells21 Thailand to receive treatment

    4. Past Medical History

    Which of the following conditions are you currently being treated or have been treated for
    in the past (please check the appropriate boxes):

    Heart Disease
    Seasonal Allergies
    High Cholesterol
    Glaucoma
    High Blood Pressure
    SeizuresStrokeMigraines
    Low Blood Pressure
    Depression
    DiabetesHypoglycemia
    Kidney problems
    Asthma
    Liver Problems
    Emphysema
    Arthritis
    Pulmonary Fibrosis
    Thyroid Problems
    Chronic Bronchitis
    Prostate Problems
    Have you ever been diagnosed with any form of cancer?
    YesNo
    Please describe any current or past medical condition that is not included in the list above:
    Have you ever been hospitalized?
    YesNo
    Please list all past surgeries:
    Have you ever received a blood transfusion?YesNo

    5. Allergies & Adverse Drug Reactions

    Are you allergic to penicillin or any other drug?YesNo

    6. Social & Preventative History

    Do you currently smoke or chew tobacco?YesNo
    If No, Have you in the past?YesNo
    Do you drink alcohol, beer, or wine?YesNo
    If No, Have you in the past?YesNo

    7. Family History

    Has any member of your family had any of the following illnesses? If yes, please place an “X” in the appropriate boxes to identify all illnesses/conditions of your blood relatives.

    Mother Father Brother Sister Grandparents Other
    Breast Cancer Mother Father Brother Sister Grandparents Other
    Colon Cancer Mother Father Brother Sister Grandparents Other
    Other Cancer Mother Father Brother Sister Grandparents Other
    Heart Disease Mother Father Brother Sister Grandparents Other
    High Blood Pressure Mother Father Brother Sister Grandparents Other
    Diabetes Mother Father Brother Sister Grandparents Other
    Liver Disease Mother Father Brother Sister Grandparents Other
    Depression Mother Father Brother Sister Grandparents Other
    Psychiatric Illness Mother Father Brother Sister Grandparents Other
    Other Mother Father Brother Sister Grandparents Other

    8. Female History

    Have you ever had a breast biopsy?YesNo

    9. Male History

    10. Review Of Symptoms

    Do you currently have any of the following symptoms? Please check all appropriate boxes:
    Eyes, ears, nose & throat   Muscle, joint, bone
    Blurred vision Yes   Swelling of ankles or legs Yes
    Other change in vision Yes   Weakness or numbness in: Yes
    Loss of hearing Yes   Arms or hands Yes
    Ringing in ears Yes   Hips Yes
    Sinus problems Yes   Legs or feet Yes
    Hoarseness Yes   Muscle pain Yes
    Nose bleeds Yes   Neck or shoulders Yes
      Back pain Yes
    Pulmonary   Joint pain Yes
    Shortness of breath Yes  
    Persistent cough Yes   Neurological
    Coughing up blood Yes   Blackouts or loss of consciousness Yes
    Wheezing Yes   Poor sleep Yes
      Headaches Yes
    Cardiovascular   Dizziness Yes
    Chest pain Yes   Loss of memory Yes
    Irregular beat / Tachycardia Yes   Speech problems Yes
    History of poor circulation Yes  
    History of Angina or heart attack Yes   Genitourinary
      Frequent or painful urination Yes
    Gastrointestinal   Blood in urine Yes
    Poor appetite Yes   Incontinence Yes
    Abdominal pain Yes  
    Indigestion Yes   Skin
    Trouble swallowing Yes   Itching Yes
    Diarrhea Yes   Easy bruising Yes
    Constipation Yes  
    Change in bowel habits Yes   Endocrine
    Nausea or vomiting Yes   Change in tolerance to hot or cold temperatures Yes
    Rectal bleeding or blood in stools Yes   Excessive thirst Yes
    Weight gain/loss of 10+ lbs during last 6 months Yes   Hot flashes Yes

    11. Required Assistance

    Do you need assistance when walking?
    YesNo
    Do you require a wheel chair?
    YesNo
    Have you received a stem cell treatment before?YesNo

    Declaration

    I hereby declare that all information provided in this form is correct and true, to the best of my knowledge. I understand that not disclosing known underlying disease or health conditions may affect my suitability and/or acceptance for medical treatment.

    *You will automatically receive an Email copy of this form for safe keeping.

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