Conditions

What Condition(s) Are You Seeking Treatment For: Diagnosis Date:

Multiple Sclerosis

Type of MS: MRI Detection of Brain or Spinal Lesions

Yes No

Experiencing Drop Foot?

Yes No

Which Foot?

Experiencing Bladder Issues?

Yes No

Brain Fog?

Yes No

Parkinson's

Primary Motor Symptoms: Secondary Motor Symptoms: Non-Motor Symptoms:

COPD

Have you had a pulmonary test?

Yes No

Date of Last Pulmonary Function Test

Are you using Oxygen?

Yes No

How Many Liters? How Many Liters Per Day?

Have you been hospitalized for COPD in the last 12 months?

Yes No

Number of times hospitalized:

Oxygen Saturation Level: Have you been diagnosed With Pulmonary Fibrosis?

Yes No

Alzheimer's

Are You Experiencing Memory Loss?

Yes No

Do You Have Difficulties Performing Tasks?

Yes No

Do You Have Language Problems?

Yes No

Able to participate in family and social activities?

Yes No

Changes In Mood And Behavior?

Stroke

What Type of Stroke Did You Have? Are you experiencing paralysis?

Yes No

What part of body experiencing paralysis?

Are you having difficulty with cognitive ability?

Yes No

Are you having difficulty with swallowing?

Yes No

Are you having difficulty with speech?

Yes No

Osteoarthritis

Where is your Osteoarthritis Located: Have you been advised to have joint replacement?

Yes No

What Joints Were Suggested? Do you have full range of joint motion?

Yes No

When was last your last MRI?

Rheumatoid Arthritis

Where is the joint pain?: Do You Have Joint Inflamation?

Yes No

Do You Have Morning Stiffness?

Yes No

Do You Have Bronchitus?

Yes No

Do You Get Chronic Sinus Infections?

Yes No

Is This Negatively Effecting My Daily Activities?

Other - Please Enter Condition Below

Please Describe Your Condition:

StemGenex® a U.S. Leader in Stem Cell Therapy

Conditions

Multiple Sclerosis

Parkinson's

COPD

Alzheimer's

Stroke

Osteoarthritis

Diabetes

Rheumatoid Arthritis

Other - Please Enter Condition Below