Intake form

Intake Form

Sent to Medical Team to develop the therapy plan
SELLER EMAIL!!!*
YOUR SCI EMAIL HERE
Patients' Full Name*

First NameLast Name
Patients' Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Age
Weight (in lbs)
example: 150lbs
Height (in feet and inches)
example: 5'5"
Gender*

MaleFemaleN/AIf female, pregnant or currently nursing?
Medical history*

Cancer (current)Cancer (personal history)DiabetesTaking Blood Thinners?Baby Aspirin?High Blood PressureNeurological disordersChronic InfectionsBlood DisordersSeizure disorder / previous siezureAsthma / COPD / Heart FailureImmunosuppressive medicationsOther
Do you have any allergies?*

No allergiesPeanutsSeafoodPenicillinLatexOther
"Have you recently experienced any recent weight loss, fever, unexplained fatigue?"*

NoYes, please specify
"Have you previously had Stem Cell treatment?"*

NoYes, Where, When, How Many?
Case Summary
Each point of PAIN- WHERE does it start?, Where does it radiate?, What is the level 1-10?, How do you describe it (shooting, aching, burning) ?, What makes it better?, What makes it worse?, Aggravating factors?,
Pain

0

1

2

3

4

5

6

7

8

9

10

0 is No Pain, 10 is Worst pain ever
Protocol Structure & Components
Total Number, then each amount followed by location, ALL INJECTIONS ARE MSC, PRP, EXOSOMES except IV, intrathecal are just MSC and esosomes!
Currently taking medications for pain? Blood Pressure? Diabetes? Bloodthinners?
We will go over their meds in more detail during the therapy plan call!
Relevant Surgeries?*
Smoking, Alcohol, Drug Use?*
Anything else of relevance?
Imaging reports: Please Upload any MRI, Xray, or CT final reports below: Reports only

Cancelof
This form will automatically get sent to the phycisian for treatment plan approval or revision. Please send all Xray, MRI, CT scan-- REPORTS ONLY to consultations@scistemcells.com

Dont forget to add all relevant comments to the CRM in the "notes" section.

Please allow up to 48 hours for phycisians to send back treatment plans.
Should be Empty:

Intake Form