Patient Evaluation Questioner

Dear Patient, we thank your interest on Progencell’s treatment. To evaluate your case we need to have the following information. This will help us determine if Progencell could help improve your medical condition. If necessesary, please attach previous lab studies, medical reports or any documents into an eMail and send it to info@progencell.com with your full name in the "subject" field.

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? Yes / No	Amount / Frequency:
Do you drink? Yes / No	Drinks per week:
Do you use any drugs? Yes / No	What / Frequency:
Practice any sport? Yes / No	Type / Frequency:
Have any allergies? Yes / No	Type:
Allergies to any medicine? Yes / No	Which:
Any special diet? Yes / No	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:
For Female Patients
Number of pregnancies:	Vaginal births:	C-sections:	Abortions:
Menopause:
Using hormone therapy:

Important: After your case is approved for treatment, we will require the following blood tests:

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

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

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.