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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