Medical History Form
Full Name
*
First Name
Middle Name
Last Name
Suffix
DOB
*
-
Month
-
Day
Year
Date Picker Icon
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Email Address
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height
*
Weight
*
Biological Sex
*
Please Select
Male
Female
Other
Decline to Answer
Emergency Contact
Name
Relationship
Phone Number
TREATMENT MENU
Please select the below categories you are seeking treatment for.
Autoimmune
Please Select
Crohn’s
Dermatomyositis
Devic Disease
Diabetes
Hashimoto’s
Lupus
Lyme
Myasthenia Gravis (MG)
Moto Neuron Disease (MND)
Pemphigus
Polymyositis
Psoriasis
Rheumatoid Arthritis (RA)
Scleroderma
Other
Cardiovascular
Please Select
Cardiomyopathy
Congestive Heart Failure (CHF)
Ischemic Heart Disease
Myocardial Infarction (MI)
Stroke
Other
Pulmonary
Please Select
Asthma
Chronic Bronchitis
COPD
Emphysema
Pulmonary Fibrosis
Other
Orthopedic
Please Select
Ankle
Back & Spine
Elbow
Foot
Hand & Wrist
Hip
Knee
Shoulder
Other
Neurological
Please Select
ALS
Alzheimer’s (AD)
Ataxia
CIDP
Concussion
CTE
Dementia
Fibromyalgia
Multiple Sclerosis (MS)
Occipital Migraines
Parkinson’s (PD)
Peripheral Neuropathy
Spinal Cord Injury (SCI)
Traumatic Brain Injury (TBI)
Other
Autism
Please Select
Autism
Facial Rejuvenation
Please Select
Facial Rejuvenation
Fertility
Please Select
Fertility
Sexual Wellness
Please Select
Decreased Sex Drive
Dyspareunia
Erectile Dysfunction (ED)
Hypoactive Sexual Desire Disorder
Orgasmic Disorder
Sexual Arousal Disorder (SAD)
Other
Healthy Aging
Please Select
Healthy Aging
Diagnosis
Date of Diagnosis
Date of Last Appointment
Description of Condition
TREATMENT NOTES
Please provide a detailed explanation as to why you are seeking Stem Cell Treatment.
Check the symptoms that you' re currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
Symptom Frequency
Daily
Weekly
Monthly
Annually
Please rate your pain level on a scale of 1 - 10.
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Please rate how much your condition affects your life on a scale of 1 - 10.
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
MEDICATION
Are you currently taking any medication?
Yes
No
If yes, please list all of your medications, vitamins and supplements that you are currently taking. Assure to include frequency and dosage.
Have you received stem cell treatment in the past?
Yes
No
If yes, please list the provider, location and date of treatment.
Have you ever received exosome or PRP treatment in the past?
Yes
No
If yes, please provide the date and location of treatment.
ALLERGIES
Do you have any known allergies?
Yes
No
Not Sure
If yes, please list allergy and reaction.
MEDICAL HISTORY
Please check the boxes indicating issues you've experienced.
Anxiety
Arthritis
Ashtma
Bleeding
Cancer
Cardiac
Chest Pain
Diabetes
Digestive
Heart Attack
High Blood Pressure
Kidney
Liver
Neurological
Prostate
Pulmonary
Seizures
Sleep Disorders
Thyroid
Tuberculosis
Other
If you have selected yes to any of the conditions above, please provide date of diagnosis and any relevant details for our medical team.
Have you had any surgeries in the past?
Yes
No
If yes, please list all past surgeries and date of procedures.
Are you pregnant or breastfeeding?
Yes
No
Please describe any other relevant health information not discussed on this form.
Preferred Consultation Call Time
**Please note all times are in Pacific Standard Time (PST)**
RELEASE OF PATIENT RECORDS
I hereby authorize the doctor rendering services to release any information required in the course of my examination or treatment.
Signature
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Referred by:
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After clicking "Submit," please confirm your signature and select "Sign Document."
SUBMIT
SUBMIT
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