Patient Evaluation Form

Thank you for your interest in ProgenCell. Please fill out and submit the Confidential Candidate Application below.

To evaluate your case we will need the following information. This will help us determine if ProgenCell could consider you eligible for this protocol and perhaps help improve your medical condition.

Your case will be evaluated and answered in the next 72 hr.

Your information is considered CONFIDENTIAL thus it is handled with total discretion. Your data will not be shared with any institution and it is not used to send spam email.

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:
Have any allergies?
yesno
Type:
Allergies to any medicine?
yesno
Which:
Any special diet?
yesno
Explain:

Current Illness

Diagnostic:
First Symptom Date: Diagnostic Date:
Initial Symptoms:
Available Lab Studies:
Available X-Rays:
Treatments received on the past:
Current Symptoms:
Other Illness 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)

Case Evaluation Form

* All Testimonials are from real patients. The results shown are typical but not guaranteed. The outcome of the treatment is uncertain and depends on each patient condition. The testimonials displayed (text, audio and/or video) are given verbatim except for correction of grammatical or typing errors. Some have been shortened. In other words, not the whole message received by the testimonial writer is displayed, when it seemed lengthy or not the whole testimonial seemed relevant for the general public.
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