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Stem Cells Medical Questionnaire

Personal Information

Gender
Do you have a passport?:

Emergency Contact

Surgery Preferences

Desired Medical Procedure.
Desired Destination.
Proposed Surgical Date

PRIMARY HEALTHCARE

Please name your medical condition or disease:
The reason why I need this examination is:
When were you diagnosed with this medical condition?
Please list all medication you are currently taking:
Please list all supplements you are currently taking:
Is your general health good?
Has there been a change in your health within the last year?
Have you gone to the hospital or emergency room or had a serious illness the last three years? *
Are you being treated by a physician now?
Are you in pain now?
Have you done any spinal cord surgery?

PERSONAL MEDICAL HISTORY

Please select which of the following have you experienced:
If you have experienced any other (explain)
Have you suffered from any of the following?
Diabetes
Diabetes while pregnant
Asthma
Respiratory/Breathing problems
Arthritis or joint pain
Kidney or urinary disorder
Neurological disorder
Psychological/nervous disorder
Gallstones
Thrombosis or clotting disorder
Gastric or duodenal ulcer
Hepatitis or liver disease
High blood pressure
Heart disease
High cholesterol
Anemia or bleeding disorder
Varicose veins or leg swelling
Eczema or skin condition
Hayfever or Rhinitis
Back pain

SMOKING/ALCOHOL/DRUGS

Recreational Drug Use?
Smoking Habit?
Any allergies:
Alcohol Consumption?

WOMEN ONLY

Are you or could you be pregnant?
Are you nursing?
Are you taking birth controlling pills?

CHECKLIST OF PREVIOUS ILLNESSES

Do you have any other diseases or medical condition NOT listed on this form?

Med Tourism Co LLC (www.medicaltourismco.com) connects patients to one of the best hospitals in the world. Med Tourism Co LLC does not provide advice on medical treatments nor makes claims or guarantees on the outcome of any medical treatment or surgery. Before making any medical related decision you must thoroughly discuss & seek advice from a qualified medical professional.

The information I have provided is true and accurate and to the best of my knowledge.





*Please review our full disclaimers, Terms & Conditions and, Health Privacy & Confidentiality Statement. Individual results may vary. The statements on this website have not been evaluated by the FDA or any medical professional.

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