Medical Form Bangkok Stem Cells

    Emergency Contact

    (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.)

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

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

    (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.