Brexo Bio Medical History Form

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

PrefixFirst NameLast Name
Phone Number:*

Country CodeArea CodePhone Number
Email:*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

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

MonthDayYear
Date
Height:
Weight:
Body weight in pounds
Gender:
Condition For Treatment:*

Multiple SclerosisParkinson's DiseaseRheumatoid ArthritisOsteoarthritis / Joint IssuesDiabetesTraumatic Brain InjurySpinal Cord InjuryStrokeAuto-ImmuneAge ManagementFibromyalgiaOther
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:*

CancerChest PainCardiac ConditionsHeart AttackStrokeBlood ClotsRespiratory IssuesUrinary ConditionsKidney DiseaseLiver DiseaseNeurologicalPsychiatricGastrointestinalMusculoskeletalSkin ConditionsNone 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?

DailyWeeklyMonthlyOccasionallyNever
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) Cancelof
Female Specific
Date of Last Mammogram?*

MonthDayYear
Date
Results of Mammogram?
Male Specific
Date of Last PSA?

MonthDayYear
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:*

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DateTime*
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Patient Information & Medical History Form