Confidential Medical History Form -

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Confidential Medical History Form

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Date*
PATIENT INFORMATION
Patient's name*
Nombre del paciente
Date of birth*
Address*
Address City State Postal code Country
Home phone
Mobile phone*
Fax number
Email*
Marital status
Estado civil
Occupation
Ocupación
Referred by
PARENT/GUARDIAN INFORMATION
Guardian's Name
Address
Address City State Postal code
Home phone
Mobile phone
Email
EMERGENCY CONTACT INFORMATION
Name*
Name
Relationship with the patient
Relationship with the patient
Home phone
Mobile phone*

TREATMENT REQUIREMENTS
Please confirm that you have read and understand the requirements below to receive treatment:
Consentimiento*
I understand that this is a patient-funded treatment*
This is a patient-funded treatment and unfortunately cannot be covered by any insurance provider, which will require the patient to pay for the cost of the treatment. The cost will vary depending on the type of treatment, the condition(s) of the patient, and the method of delivery needed.
Consentimiento
I am able and willing to travel for treatment (select all that apply)
Consentimiento
I am able to travel within my state
Consentimiento
I am able to travel within the US.
Consentimiento
I am able to travel outside of the US.
Consentimiento
I am able to travel to neighboring states
PAST MEDICAL HISTORY
Primary condition for which you seek treatment*
Diagnosis date*
Describe all symptoms, dates of onset, and any other pertinent information*
Which of the following conditions is currently being treated or has been treated in the past? (check the appropriate boxes):*
- Heart disease
- Seasonal allergies
- High cholesterol
- Glaucoma
- High blood pressure
- Seizures
- Stroke
- Migraines
- Low blood pressure
- Depression
- Diabetes
- Hypoglycemia
- Kidney problems
- Asthma
- Liver problems
- Emphysema
- Arthritis
- Pulmonary fibrosis
- Thyroid problems
- Chronic bronchitis
- Prostate problems
- None
Have you ever been diagnosed with any type of cancer?*
- Yes
- No
Type of Cancer*
Condition*
Date of diagnosis*
Describe any current or past medical conditions not included in the above list
Have you ever been hospitalized?*
- Yes
- No
Why was hospitalization necessary?*
Please list all previous surgeries
Surgery (Indicate Date) Surgery (Indicate Date)
Have you ever received a blood transfusion?*
- Yes
- No
Date*

ALLERGIES AND ADVERSE REACTIONS TO MEDICATIONS
Blood type*
- A+
- A-
- B+
- B-
- O+
- O-
- AB+
- AB-
- I don't know
Are you allergic to penicillin or any other medication?*
- Yes
- No
If yes, please list*
Please list your current medications*
Nutritional supplements / Herbal preparations
SOCIAL AND PREVENTIVE HISTORY
Do you currently smoke or chew tobacco?*
- Yes
- No
How many packages per...*
Day Week Month
Have you done it in the past?*
- Yes
- No
How many packages per...*
Day Week Month
Do you drink alcohol, beer or wine?*
- Yes
- No
How many drinks per...*
Day Week Month
Have you done it in the past?*
- Yes
- No
How many drinks per...*
Day Week Month
Age*
Weight*
Height*
Sex*
Date of your last medical check-up*
Doctor
First
Phone number
Results of your last medical check-up*

FAMILY HISTORY
Has any member of your family had any of the following illnesses? If yes, please place an “X” in the appropriate boxes to identify all diseases/conditions of your blood relatives.
Breast Cancer*
- Myself
- Mother
- Father
- Sister
- Grandparents
- Other
- None
Colon Cancer*
- Myself
- Mother
- Father
- Sister
- Grandparents
- Other
- None
Another type of Cancer*
- Myself
- Mother
- Father
- Sister
- Grandparents
- Other
- None
Heart disease*
- Myself
- Mother
- Father
- Sister
- Grandparents
- Other
- None
High blood pressure*
- Myself
- Mother
- Father
- Sister
- Grandparents
- Other
- None
Diabetes*
- Myself
- Mother
- Father
- Sister
- Grandparents
- Other
- None
Liver disease*
- Myself
- Mother
- Father
- Sister
- Grandparents
- Other
- None
Depression*
- Myself
- Mother
- Father
- Sister
- Grandparents
- Other
- None
Psychiatric illness*
- Myself
- Mother
- Father
- Sister
- Grandparents
- Other
- None
Other (Please specify)
Female History
Date of your last Mammogram
Result
Have you ever had a breast biopsy?
- Yes
- No
Biopsy Result
Male History
Date of your last PSA
PSA Result
SYMPTOM CHECK
Do you currently have any of the following symptoms? Check all that apply:
Eyes, Ears, Nose, Throat
- Blurry vision
- Another change in vision
- Hearing loss
- Ringing in the ears
- Sinus problems
- Hoarseness
- Nosebleeds
Muscle, Joint, Bone
- Swollen ankles or legs
- Weakness or numbness in:
- Arms or hands
- Hips
- Legs or feet
- Muscle pain in:
- Neck or shoulders
- Back pain
- Joint pain
Pulmonary
- Breathing difficulty
- Persistent cough
- Coughing up blood
- Wheezing
Neurological
- Blackouts or loss of consciousness
- Bad sleep
- Headaches
- Dizziness
- Memory loss
- Speech problems
Cardiovascular
- Chest pain
- Irregular heartbeat / Tachycardia
- History of poor circulation
- History of angina or heart attack
Genitourinary
- Frequent or painful urination
- Blood in the urine
- Incontinence
Gastrointestinal
- Little appetite
- Abdominal pain
- Indigestion
- Swallowing difficulty
- Diarrhea
- Constipation
- Change in bowel habits
- Nausea or vomiting
- Rectal bleeding or blood in the stool
- Weight gain/loss of more than 10 pounds in the past 6 months
Endocrine
- Change in tolerance to cold or hot temperatures
- Excessive thirst
- Hot flushes
Skin
- Itching
- Bruises easily
Do you need help walking?*
- Yes
- No
Do you need a wheelchair?*
- Yes
- No
Other requirements?
Have you received a stem cell treatment before?*
- Yes
- No
Date of your last treatment*
If yes, describe*
What do you intend to achieve with the treatment you are seeking?*
Please add to the file the medical records that can support the diagnosis of our physicians.
Drop files here or

Accepted file types: (iejpg, gif, png, pdf, Max. file size: 256 MB.
Consent*
I agree to the privacy policy.*
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Email
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Disclaimer: Stem cell therapy is a great alternative therapy but offers no guarantees and is not promoted as a cure. This is similar to many other conventional medical treatments. A complete review of the patient’s medical history is required to determine eligibility and approval for stem cell therapy. All personal information provided is for internal and medical use with our medical providers only. Global Stem Cells Group headquarters are located in Miami, Florida and is a marketing resource company and provider network for Cellular Hope Institute, in Cancun Mexico. Global Stem Cells Group in Miami Lakes, Florida is not a stem cell treatment facility or surgical center. Treatments are not conducted in our offices or in the U.S.A since these advanced cellular therapies using high-concentrated cultured and expanded cells are not yet approved by the FDA. All cellular therapies are conducted in Cancun, Mexico, as it is regulated by the ministry of health, COFEPRIS and other local authorities. all treatments are performed within the legal limits and regulatory framework for the country in which the specific medical provider practices.

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