STEM CELL PROGRAMME QUESTIONNAIRES
Name
*
I/C Number
*
Gender
*
Nationality
*
Contact Number
*
-
Area Code
Phone Number
Email
*
example@example.com
1. What is your current condition or ailment for which you are seeking a Stem Cell programme?
*
Arthritis
Multiple Sclerosis
Parkinson's
Diabetes
Heart disease
Osteoarthritis
Other
2. What is the severity of your condition?
*
Not severe
Moderately severe
Very severe
3. What are your specific goals or expectations for this Stem Cell programme? (You can pick more than one)
*
Improve mobility
Improve function
Slow disease progression
Other
What is your budget for this Stem Cell programme? (Example: less than RM 10,000)
*
MYR
5. Are you able to commit to the recommended Stem Cell programme plan, including any necessary follow-up after that?
*
Yes
No
6. How much pain tolerance do you have?
*
Low
Moderate
High
7. What is your desired timeframe for completing the Stem Cell programme?
*
As soon as possible
I'm willing to wait longer
Flexible and open to discussion
Other
Submit
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