MEDICAL HISTORY FORM

Medical History Form
Please complete the Medical History Form. You are under no obligation to pursue stem cell therapy by completing this form. The purpose is to provide the medical team with the necessary insight to evaluate your circumstances, and determine if you may benefit from stem cell therapy. Your safety and privacy are the primary concerns for our Medical Team, so please be specific and accurate.

By completing this form, you are granting permission for the Medical Team and Patient Outreach members to communicate with you regarding your form and circumstances via email, phone, voice mail, and internally.

A member of the Patient Outreach team is available to assist you at 847-245-2400.

MEDICAL HISTORY FORM (2 of 7)
How did you hear about GIOSTAR?*
If "Other," please provide more detail (Website / person name) about how you heard about GIOSTAR*
First Name*
Last Name*
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Please use date picker or enter in format mm/dd/yyyy; e.g., 11/05/1963
HEIGHT
Feet*
Inches*
Weight (pounds)*
Country*
Email Address*
Phone number*
Best date and time for callback (Central Standard Time)
Address*

Street Address

Street Address Line 2 (e.g., Apt., Suite)

CityState / Province

Postal / Zip Code

MEDICAL HISTORY FORM (4 of 7)
Have you ever been diagnosed with COVID-19?*

YesNo
Date of most recent positive COVID test result*

MonthDayYear
Please use date picker or enter in format mm/dd/yyyy; e.g., 11/05/1963
Did you suffer any severe symptoms after COVID?*

YesNo
Please list the symptoms you experienced following COVID:*
Do you have a primary care physician?*

YesNo
Who is your primary care physician?*
Date of last visit to your physician*

MonthDayYear
Please use date picker or enter in format mm/dd/yyyy; e.g., 11/05/1963
Do you have a heart condition?*

YesNo
List your heart conditions*
Type "None" if you have no heart conditions
Which symptoms do you struggle with the most?*
Type "None" if not applicable

MEDICAL HISTORY FORM (7 of 7)
CONSENT

You are under no obligation to pursue Stem Cell Therapy. The purpose of this form is to provide the Medical Team with the necessary insight to evaluate your circumstances, and determine if you may benefit from stem cell therapy.

By completing this form you are granting permission for the Medical Team and Patient Outreach members to communicate with you regarding your form and circumstances via email, phone, voice mail and internally.
Yes, I would like to receive educational information on stem cell treatment options and treatment availability.

Medical History Form