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

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

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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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:

4. Past Medical History

5. Allergies & Adverse Drug Reactions

6. Social & Preventative History

7. Family History

8. Female History

9. Male History

10. Review Of Symptoms

11. Required Assistance

Declaration

Join Our Youtube Channel

Patient Evaluation Form
(Regenerative)