Auragens Medical History Form

Medical History Form
Full Name

First NameMiddle NameLast NameSuffix
DOB

MonthDayYear
Phone Number

Country CodeArea CodePhone Number
Email Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Height
Weight
Biological Sex
Emergency Contact

NameRelationshipPhone Number
TREATMENT MENU

Please select the below categories you are seeking treatment for.
Autoimmune
Cardiovascular
Pulmonary
Orthopedic
Neurological
Autism
Facial Rejuvenation
Fertility
Sexual Wellness
Healthy Aging
Diagnosis

Date of DiagnosisDate 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:

Other
Symptom Frequency
Please rate your pain level on a scale of 1 - 10.

1

2

3

4

5

6

7

8

9

10

1 is Mild, 10 is Severe
Please rate how much your condition affects your life on a scale of 1 - 10.

1

2

3

4

5

6

7

8

9

10

1 is Mild, 10 is Severe
MEDICATION
Are you currently taking any medication?
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?
If yes, please list the provider, location and date of treatment.
Have you ever received exosome or PRP treatment in the past?
If yes, please provide the date and location of treatment.
ALLERGIES
Do you have any known allergies?
If yes, please list allergy and reaction.
MEDICAL HISTORY
Please check the boxes indicating issues you've experienced.

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?
If yes, please list all past surgeries and date of procedures.
Are you pregnant or breastfeeding?
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
Referred by:
After clicking "Submit," please confirm your signature and select "Sign Document."
Should be Empty:

Medical History Form

TREATMENT MENU

TREATMENT NOTES

MEDICATION

ALLERGIES

MEDICAL HISTORY

**Please note all times are in Pacific Standard Time (PST)**

RELEASE OF PATIENT RECORDS

Please note all times are in Pacific Standard Time (PST)