Brexo Bio Medical History Form

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Stem Cell Therapy
Patient Information & Medical History Form
Full Name: *

Prefix First Name Last Name
Phone Number: *

Country Code Area Code Phone Number
Email: *
example@example.com
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How did you hear about Brexo Bio?
Date of Birth: *

Month Day Year
Date
Height:
Weight:
Body weight in pounds
Gender:
Condition For Treatment: *

Multiple Sclerosis Parkinson's Disease Rheumatoid Arthritis Osteoarthritis / Joint Issues Diabetes Traumatic Brain Injury Spinal Cord Injury Stroke Auto-Immune Age Management Fibromyalgia Other
Other Medical Conditions:
List All Other Conditions
Cause of Diagnosis if known:
Diagnosis Date:
List All Symptoms: *
Example: Pain, Tremors, Spasms, etc.
Have you been diagnosed or experienced any of the following medical issues? Check all that apply: *

Cancer Chest Pain Cardiac Conditions Heart Attack Stroke Blood Clots Respiratory Issues Urinary Conditions Kidney Disease Liver Disease Neurological Psychiatric Gastrointestinal Musculoskeletal Skin Conditions None of the above
If you checked any of the above issues, please explain: *
List All Rx Medications: *
Example: tramadol, aspirin, metformin
List All Supplements *
Example: multi-vitamins, fish oil, CoQ10
Allergies To Medications: *
List all allergies to medications & specific negative reactions
Do you use or do you have history of using tobacco?
If yes, when was last use?
Do you use or do you have history of using any drugs?
If yes, when was last use?
How often do you consume alcohol?

Daily Weekly Monthly Occasionally Never
Surgeries: *
Type of Procedures & Dates
Hospitalizations: *
Reason for Hospitalizations & Dates
Is Patient on Hospice? *
Is Patient Ambulatory *
Is Patient Currently Working? *
Please Upload Medical Records:

Browse Files
Example: Labs, MRI, CT scans (Only upload pertinent medical records if available) Cancel of
Female Specific
Date of Last Mammogram? *

Month Day Year
Date
Results of Mammogram?
Male Specific
Date of Last PSA?

Month Day Year
Date
PSA Level?
Erectile Dysfunction?
By signing my name below, I certify that the above medical information is true and accurate to the best of my knowledge. I understand that there is no obligation to receive treatment from Brexo Bio, Inc. or any of it's providers. Information contained in this medical history form will be used for medical evaluation purposes only.
Patient Signature: *

Clear
DateTime *
Should be Empty:

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Patient Information & Medical History Form