Case Evaluation Form

PERSONAL INFORMATION:




Date:
Full Name:
Age:
Phone Number:
Best Time / Day to Contact:
eMail:
Religion: (optional)

Gender: (Male / Female)
Marital Status:
Weight:
Height:
Place of Birth:
Residence: (City, Country)
Do you smoke?
yesno
Amount / Frequency:
Do you drink?
yesno
Drinks per week:
Do you use any drugs?
yesno
What / Frequency:
Practice any sport?
yesno
Type / Frequency:
Do you have any allergies?
yesno
Type:
Allergies to any medicine?
yesno
Which:
Are you on any special diet?
yesno
Explain:
Have you had cancer within the last 5 years?
yesno
Type / Date / Treatment:

Current Illness

Diagnosis:
First Symptom Date:
Diagnosis Date:
Initial Symptoms:
Available Lab Studies:
Available X-Rays:
Treatments Received in the Past:
Current Symptoms:
Other Illnesses Present:
Current Medication:
Previous Surgeries: (explain cause and date)
Special Requirements: (Wheelchair, transportation, communication)
Additional Comments / Questions:

Miscellaneous

How did you find out about ProgenCell?:

For Female Patients

Number of Pregnancies: Vaginal Births: C-Sections: Abortions:
Menopause:
Using Hormone Therapy:

Important: After being approved to participate in this research protocol, and before your arrival at ProgenCell®, we will require the following blood tests:

  • Complete Blood biometrics (with platelets)
  • Prothrombin time (PT)
  • Partial thromboplastin time (PTT)
Whatsapp

START TYPING AND PRESS ENTER TO SEARCH