Health Questionnaire

Confidential evaluation of medical history

FIRST NAME (required)

MIDDLE NAME

LAST NAME (required)

CITY, STATE (required)

COUNTRY (required)

PHONE NUMBER (required)

Alt. PHONE NUMBER

BIRTH DATE (mm-dd-yy) (required)

EMAIL ADDRESS (required)

HEIGHT

WEIGHT

MEDICAL CONDITION

MEDICAL HISTORY

OTHER MEDICAL CONDITION(s)
 None Arthritis or joint problems Cancer Ulcer Blood clothing problems Depression Epilepsy Eye disease Headaches/ Migraines Heat diseases High blood pressure High cholesterol or lipids Lung condition Tyroid disease

Others

CURRENT PRESCRIPTION(S)

ALLERGIES
 Pet allergy Penicillim Morphine Codeine Aspirin Dye allergy Food allergy Seasonal allergy None

Others

OVER THE COUNTER ISSUES
 Pain reliever Flu medication Sleeping aids Anti-diarrhea Laxatives Weight loss products Acid blockers Antihistamine

Others

NUTRITIONAL/NATURAL SUPPLEMENT
Please indicate vitamins, minerals, herbs, emzymes, nurtition or protein supplements you may be taking

NUTRITIONAL/NATURAL SUPPLEMENT

FAMILY MEDICAL HISTORY
 Autoimmune disease Cancer Depression Diabetes Eye disease Epilepsy Fibrocystic breast Heart disease High cholesterol Hormone imbalance Lung disease Osteoporosis Stroke

Others

SYMPTOM FREQUENCY
Please check which applies to you
 Absent mindedness Abnormal bleeding Acne ADD or ADHD Anxiety Asthma Breathing difficulty Brittle, peeling or braking nails Chemical sensitivity Chest pressure or heavyness Chronic fatigue syndrom Constipation Declining memory Decreased quality of sleep Palpitations Feeling cold often Indigestion Infertility Irritable bowel syndrom Joint pain Loss of interest in life Loss of motivation Low blood pressure Low energy Low libido Morning stiffness Muscle pain Rapid weight gain Dirrehea Dizziness Hair loss Frequent urination Headaches or migrains Heat intolerance Insomnia Panic Attacks Sleep Apnea Psoriasis Sweet cravings Tremors Yeast infections

Others

 I have received stem cell treatment in the past

CONFIDENCIALITY STATEMENT

Your privacy is important to us and we use every care to ensure your privacy rights!
It is our policy to never allow any 3d party access to any of your personal or medical information. If you have a question on our security process or protocol please contact us immediately. In compliance with the 1966 congressional act to protect the privacy of patients protected health information, we will safeguard all client/patient information and will disclose or share only minimal information necessay for the puroses of treatment and operations.
Treatment purpose includes information regarding current or past health information necessary for A1 Stemcells staff to carry out appropriate care of the clients which may include but is not limited to: history and physical, progress notes, laboratory reports, x-ray reports, operative reports, consultation reports, hospital discharge report, hospital DNR, to be obtain from any clinic, hospital, skilled nursing facility, physician office or health care agency in the patient/client's present and future care.
Purpose of operations include the review of medical records by any peer review organization, accrediting body, state or regulatory body for statistical evaluation purposes only. Any information disclosed will be held in strict confidence and not used for any public disclosure.
If you feel that your privacy rights have been violated you may contact us and ask for the director of operations. The director will investigate all clains and will provide you with a written report of their findings and of the corrective actions taken within 10 days. We will maintain a log for each patient we service which will list what information was released and for what purpose. The patient has the right to review this log upon request.

I hereby assert that I have answered the medical questionnaire accurately, to the best of my knowledge.

ELECTRONIC SIGNATURE (required)