Medical Form Bangkok Stem Cells - Bangkok Stem Cells

Patient's First Name *

Patient's Last Name *

Date of Birth *

Gender *

Address *

City *

Zip Code / Postcode *

Country *

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? *