PrecisionBio Medical History Form

  • PrecisionBio Medical History Form 2025

  • This form is to be completed by the patient, or on the patient’s behalf, including detailed responses to all questions that apply to the applicant’s medical history and for which treatment is being considered. These details will assist the medical team in determining which of the regenerative medicine therapies is most appropriate for the patient.

    In most cases, additional information may be required, and one of our Patient Advocates will contact you to specify the medical records needed. This may include imaging, blood analysis, and other prior medical history. 

    Please allow 3-5 business days after submission of all medical records for the medical review to be completed.  Your Patient Advocate together with one of our doctors, will be in contact with you to help finalize the process. 

    Please fill out the form as accurately as possible. 

    Thank you!

     
    PrecisionBio Medical Team

    The Precision Standard in Regenerative Medicine

  • 1. Today's date*
     - -
  • 3. Gender*
  • 4. Birth Date*
     - -
  • 8. Marital status*
  • Format: (000) 000-0000.
  • 13. Date of diagnosis *
     - -
  • 15. Have you received a cancer diagnosis?*
  • 17. Have you received the Covid-19 vaccine?*
  • 18. Physical Limitations*
  • 23. Diabetes History*
  • Rows

  • MEDICAL HISTORY

  • 25. Medical History AUTOIMMUNE - Please indicate if you currently have or have previously had the condition. Select all that apply.*
  • 26. BACK & SPINE: Check if you have the condition now or have had it in the past. Select all conditions that apply.*
  • 27. CARDIOVASCULAR: Check if you have the condition now or have had it in the past. Select all conditions that apply.*
  • 28. CIRCULATORY: Check if you have the condition now. Select all the conditions that apply.*
  • 29. GASTROINTESTINAL: Check if you have the condition now. Select all that apply.*
  • 30. HEPATITIS: If you have had hepatitis, please provide type below (in other)*
  • 31. GI ENDOSCOPY: If you have had a GI Endoscopy, please provide (a) Upper GI Date and (b) Upper GI Results below (in other)*
  • 32. ELBOW: Check if you have the condition now or had it in the past. Select all that apply.*
  • 33. FOOT & ANKLE: Check if you have the condition now or had it in the past. Select all that apply.*
  • 34. HIP: Check if you have the condition now or had it in the past. Select all that apply.
  • 35. KNEE: Check if you have the condition now or had it in the past. Select all that apply.
  • 36. NEUROLOGICAL: Check if you have the condition now or had it in the past. Select all that apply.*
  • 37. PULMONARY: Check if you have the condition now or had it in the past. Select all that apply.*
  • 38. UPPER RESPIRATORY: Check if you have the condition now or had it in the past. Select all that apply.*
  • 39. RHEUMATIC SCREEN: Check if you have the condition now or had it in the past. Select all that apply.*
  • 40. ENDOCRINOLOGY: Check if you have the condition now or had it in the past. Select all that apply.*
  • 41. ALLERGY: Provide any other allergies or intolerance to medication below (in other)*
  • 42. SHOULDER: Check if you have the condition now or had it in the past. Select all that apply.
  • 43. HEALTHY LIVING: Check if you have the condition now or had it in the past. Select all that apply.
  • 44. What is the best day of the week and time to contact you?
  • Rows
  • Rows
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  • 49. When are you looking to receive medical attention?*

  • RELEASE OF PATIENT RECORDS

  • 50. Patient Privacy requires the patient or their legal representative to fill out this form. By submitting this form, you authorize the release of your protected health information (PHI) to us and also to any third party or another affiliated healthcare provider, such as an insurance company, other medical professional, medical imaging clinic, medical analysis clinic, employer, or for legal or billing purposes as may be required. This authorization will expire 1 (one) year from the date of submission. You can revoke this authorization at any time by providing a written notice of revocation.
    We have not recommended a specific treatment plan at this point in your care. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing, and treatment. By confirming below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended, and (2) you consent to treatment at this office or any other satellite office under common ownership. Until you revoke it in writing, the consent will remain fully effective. You have the right at any time to discontinue services. You have the right to discuss the purpose, potential risks, and benefits of any ordered test with your physician. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions. I voluntarily request a Physician, a mid-level provider (such as a Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other healthcare providers or their designees to perform reasonable and necessary medical examinations, testing, and treatment for the condition that has brought me to seek care at this practice. I understand that if additional testing or invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements, and I consent completely and voluntarily to their contents.

  • 51. How did you hear about PrecisionBio?*

  • Thank you!!

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