Form

Patient History Form
Stem cells are mother cells that have the potential to become
any type of cell in the body.
Please check the following conditions that apply to you

RESPIRATORY :

EmphysemaAsthmaPneumoniaUpper RespiratoryInfection BronchitisPulmonary Embolus

CARDIOVASCULAR :

Heart AttackChest PainLipids.Heart FailureHigh Blood Pressure TriglyceridesHeart MurmurIrregular Heart Beat Coronary Artery Disease

GASTROINTESTINAL :

HepatitisHepatitis AGallstonesCirrhosisHepatitis BUlcersLiver FailureHepatitis CReflux

ENDOCRINE :

DiabetesHypothyroidismHashimotoPituitaryParathyroid Hyperthyroidism

NEUROLOGIC :

HeadacheSeizuresMigrainesStrokeSpeech ProblemBell ’s palsyTremorMyasthenia GravisMultiple Sclerosis

UROLOGY :

Kidney StonesRenal FailureNephritisBPH

EYES :

CataractsBlindnessGlaucoma

MUSCULO SKELETICAL :

ArthritisTMJDegenerative Disc DiseaseGOUT Spinal StenosisFibromyalgia

HEMATOLOGIC :

AnemiaLymphoma Bleeding DisordersLeukemia (CLL)Deep Venous Thrombosis

PSYCHIATRIC :

DepressionAnxietyBi-Polar Disorder

OTOLOGY :

Hearing Loss Tinnitus/Ringing in earsVertigo/DizzinessImpacted CerumenExternal Ear InfectionPerforation of Eardrum

*Alcohol Use :

NoneMinimalModerateHeavy

*Cancer :

YesNo

*Tobacco Use :

NoneMinimalModerateHeavy

Phone no :

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