Stem Cell Questionaire
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
Height
*
Weight
*
Have you lost more than 20 pounds in the last 6 months?
Are you allergic to any foods ?
Are you allergic to any medications? If yes which ones?
Have you ever been diagnosed with cancer? If so when?
*
Have you had surgery in the past 6 months?
Have you had treatment in Mexico in the past?
Have you ever had Stem Cell Treatment in the past? Positive, Negative or No result
What type of Stem Cell Treatment do you seek?
*
JOINTS
AUTOIMMUNE/LYME
NEUROLOGICAL
ERECTILE DYSFUNCTION
DEGENERATIVE DISEASE SPINE
BEAUTY
Other
Please Explain any details
Do you have access to recent (past year) image studies (CT SCAN, MRI OR XRAYS) and labs?
YES
NO
Do you have any of these conditions?
High Blood Pressure
Diabetes
Autoimmune Disease
Heart Conditions
Other
Are you receiving treatment for the above conditions?
YES
NO
Are you interested in a phone consultation with a Stem Cell Medical Specialist?
YES
NO
Please briefly explain any other importand Medical History
Please upload your medical reports
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