Medical Form Bangkok Stem Cells - Bangkok Stem Cells

Patient’s Full Name*

Date of Birth*

Nationality*

Gender*

Address*

Phone*

Email address*

Emergency Contact

Name*

Phone*

Current Diagnosis*

Disease/Injury History and Previous Treatments*

(Brief disease/injury history and previous treatments. When did the symptoms start? Worsening or not, any modifier? Any operations and medications? Any physiotherapy? The effectiveness of any treatments.)

Current Medications*

(Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs, etc. Medication Dose (e.g., mg/pill). How many times per day?)

Present Symptoms and Physical Impairements*

Results of MRI, CT, X-ray, and/or EMG, etc, Results of Laboratory Examination (Blood Test and Others)*

(Please include the date of the tests, as well as any other screening tests performed for any other conditions.)

Personal and Family Medical History*

(Please indicate the current status of your immediate family members. Please indicate family members (parent, sibling, grandparent, aunt or uncle) with any suspected familiar health problems.) (Have you been diagnosed, treated and/or medicated for any other conditions in the past? If yes, tell us the conditions and Operated/Treated/Medicated? Please inform us about tobacco and alcohol use.)

If you have any of the below, please mention.

1. A history of severe allergies *

2. A ventilator or a pacemaker *

3. Having complicated and severe organic functional disturbances. Which organ?*

4. Having infectious diseases such as HIV, RPR, A/B/C/D/E types of hepatitis, and active tuberculosis, etc *

5. Malignant tumors *

6. Coagulation disorders *

7. Severe immune diseases *

8. A cerebral ventricular shunt *

9. Any immunizations in the past 3 months? *

Are you human?*

This field should be left blank

Stem Cells - Medical Form
Last Name*
Nationality*
Address*
Email*
Phone*
Description