Patient Information：
Date of Entry：

Your Information：
Name：
Gender：MaleFemale
Date of Birth： ( years old)

Height：cm Weight：kg

Address：
Phone Number：
Email Address：

Concerns you want to improve：
PainDiabeteLiver functionKidney functionSexual functionBeauty (skin/hair growth)Prevention of cognitive decline
Other

Treatment performed at another hospital：

Surgery：YesNo	Year： Location：
Anti-aging：YesNo	FillersBotoxPeelingThread liftLaserLiposuction
Regenerative Medicine：YesNo	When did the receive the treatment? Treatment： PRPAPSFGFACRSSupernatant fluid treatmentStem cell therapy Where was the treated? Country： —Please choose an option—Dubai(UAE)KoreaMalaysiaMexicoThailandUkraineOtherOther Area： Clinic Name： Please provide details about your stem cell therapy (if applicable) Administration method： IV infusionlocal injection Injection site： Number of administrations： times Number of cells administered： Effectiveness： —Please choose an option—GoodPoorNo Change
Pain treatment：YesNo	ChiropracticAcupunctureMassageInjection Other：
Data from Other Hospitals：YesNo	Medical CertificateTreatment Progress RecordBlood Test ResultsX-rayCT ScanMRIPET ScanSurgical RecordRadiation Therapy RecordChemotherapy Record If you have medical records from another hospital, please upload them here. Attachment file：
Other：

Illness under treatment：
NoneHigh blood pressureDiabetesLiver disorderKidney disorderHeart diseaseCerebralHemorrhage/Cerebral infarctionAsthma/COPDImmune diseaseMalignant tumorMental diseaseInfertility
Treatment of infectious diseases：YesNo
If yes, which of the following infectious diseases are you being treated for? (Select all that apply)
Hepatitis (Type A)Hepatitis (Type B)Hepatitis (Type C)TuberculosisSyphilisHIV/AIDSHTLV−1

Current Medications/Supplements：
If yes, please list the medications you're taking, including the name and dosage(amount of active ingredient e.g. mg).
Blood thinners：YesNo
Blood thinning supplements：YesNo
Hypertension medications：YesNo
Diabetes medications：YesNo
Female hormone therapy：YesNo
Psychiatric medications：YesNo
Others：

Social History
Alcohol：Do not drinkDrink ( —Please choose an option—1 cup of sake1 large bottle of beer2/3 cup of shochu/awamori1 double shot of whiskey1/3 bottle of wineDrink more than this amount )
Tobacco：Do not smokeSmoke ( cigarettes/day )

Medical History
Allergies：
Food：NoneKiwiBananaAvocadoPapayaMangoMelonFigCherryEggSoyWheatPeanutsBlue fish (e.g., mackerel, sardine)Other
If you selected "Others," please specify the food.
Severity of Allergic Reaction MildModerateSevere

Medication：NoneAspirin (e.g., Bufferin)Ibuprofen (e.g., Brufen, Eve)Loxoprofen (e.g., Loxonin)Anesthetics (e.g., Xylocaine)Other
If you selected "Others," please specify the medication.
Severity of Allergic Reaction　MildModerateSevere

Antibiotics/Antifungals：NonePenicillin antibioticsCephalosporins (e.g., Cefzon)StreptomycinAmikacinAminoglycosides (excluding streptomycin, amikacin)Amphotericin BOther
If you selected "Others," please specify the medication.
Severity of Allergic Reaction　MildModerateSevere

Others：NoneLatexAlcoholIodine
Severity of Allergic Reaction　MildModerateSevere

Have you ever felt sick from anesthesia such as dental anesthesia (xylocaine) or gastroscopy?YesNo

Are you pregnant or at risk of pregnancy (miscarriage or bortion within the last 3 months)?YesNo

Emergency Contact：
Name：
Phone Number：
Email Address：
Relationship with Patient：

Additional Notes：
Please include any additional information that may be relevant to your overall health condition：

Source Questions
Please select the purpose of your inquiry.
Make an appointmentAsk about consultation and treatmentInquire about fees and paymentAsk about other mattersNeed immediate treatment

How did you hear about our clinic?
Friend's referralAgent's referralAttended seminarSaw websiteInstagramFacebookWeChatOther
If you select other, please specify how you found out about the clinic.
It would be helpful if you could provide the name of the friend or agent who referred you.

Thank you very much for your cooperation.