testing form Personal information *Date: (DD/MM/YYYY) *Full Name: *Birthday: (DD/MM/YYYY) *Phone Number: Best time / day to contact: *Email: Religion: Gender: MaleFemale Marital Status: Weight: Height: Place of birth: Residence: (City, Country) Did you smoke? YesNo Amount / Frequency: Did you drink? YesNo Drinks per week: Did you use any drugs? YesNo What / Frequency Practice any sport? YesNo Type / Frequency Have any allergies? YesNo Type: Allergies to any medicine? YesNo Which: Special diet? YesNo Explain: Do you have or had some type of Cancer in the last 5 years? YesNo Type / Date / Treatment: 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 Additional comments / questions: Number of pregnancies: Vaginal births: C-sections: Abortions: Menopause: Using hormone therapy: