Survey | Stem Cell Therapy Clinics

Welcome to the StemGenex Medical Group Medical History Form

This medical history survey is used to determine a patient’s candidacy for safe and effective stem cell therapy through StemGenex Medical Group.

Please fill out as many questions as possible so we can determine if our stem cell clinic is right for you.

Contact Name

Phone

Subject

Description

First Name

Last Name

Gender

Date Of Birth

Height

Weight

Street Address

City

State / Province / Region

ZIP /Postal Code

Country

Home Phone

Work Phone

Cellular Phone

Fax Number

Email Address

Occupation

Marital Status

Referred By

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Condition for Treatment

Date of Diagnosis

Describe All Symptoms You Are Having In

Currently On Any Medications

Please List Medications

Anticoagulated?

When was Your Last Vaccination?

Do You Smoke?

Is Patient a Minor?

Do You Consume Alcohol?

What Do You Smoke?

How Many Do you Smoke?

What Type of Alcohol Do You Drink?:

Nutritional Supplements?

Please List Supplements and Dosage/Sched

Have You Ever Been Diagnosed with Cancer

What Type of Cancer?

When Were you Diagnosed with Cancer?

What is the Status of your Cancer?

Have you had a PSA test?

Date of your Last PSA

Result of PSA test?

Neurological System Symptoms

Pulmonary System Symptoms

Cardiovascular Problems

Circulatory Symptoms

Gastrointestinal Problems

Overweight Problems

Upper Respiratory Problems

Rheumatic Screen

Endocrinological System Symptoms

Do you Have Allergies?

Vision Symptoms

Allergy History

Date of Last Medical Check-up

Physician Name

Physician Phone

Results of Last Check-up

Can you Send us the Check-up Results?

Do you Have Any of these Symptoms

Describe your Symptoms

Surgical Procedures (Date,Description)

Hospitalizations (Date,Reason)

Have you been on growth hormone therapy?

How Long Have you taken Growth Hormones?

Number of IU's of HGH injected per week?

Family History

Do you need assistance when walking?

Do you require a wheelchair?

How way me assist you when walking?

How may we assist you in a wheelchair?

Other Physical Requirements?

Confirmation Phone Number

Why are You Taking Anticoagulants?

Anticoagulants Since When?

How Much to Drink?

Family History Other

PATIENT APPLICATION STATEMENT AND AGREEMENT

As a world leader in Stem Cell therapy and research, StemGenex® provides patients access to cutting-edge stem cell therapy utilizing the most advanced clinical protocols. Safety and efficacy are the primary focus of these treatments which are performed by board certified physicians including scientific protocols set forth by our PhD neuroscientist. Please be aware of the following important disclosures being made:

The science of treatment using adult stem cells is in its initial stages.
The treatments described on www.StemGenex.com are not approved by the US FDA and are not currently considered to be standard of care for any condition or disease.
There could be significant and unknown risks associated with adult stem cell treatments, as long-term studies have not been performed.
As with all medical procedures, stem cell therapy through StemGenex does not provide or imply a guarantee of safety or effectiveness. Treatments by licensed doctors will only be performed after the patient understands and agrees to informed consent.

By checking this box you agree that you have read and understand all of the statements above.

By checking the box below I certify that my complete medical history is disclosed on this form including but not limited to a diagnosis, all surgeries, medications, hospitalizations and allergies. I understand omitting information may disqualify me as a candidate for treatment.

StemGenex® takes great pride in our response time to your inquiry and providing you with the highest level of service possible. You should expect to hear back shortly from your patient advocate to confirm that we have received your application form. Please list the single best phone number to reach you, Monday-Friday 8am-6pm Pacific Standard Time (PST).

Contact StemGenex

Welcome to the StemGenex Medical Group Medical History Form