• Shimotakaido 5-4-10, Suginami-ku, Tokyo

Medical Questionnaire for Regenerative Treatment

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Medical Questionnaire for Regenerative Treatment

For those interested in regenerative medicine, please fill out and submit the questionnaire before your consultation. By sharing your situation in advance, this will help shorten the consultation time and contribute to a more in-depth and productive session.

※Disclaimer: This form is used to collect information about patients and used for internal purposes only. The information you supply is confidential and will be treated accordingly.

    Patient Information：
    Date of Entry：

    Your Information：

    Gender：
    Date of Birth：



    Concerns you want to improve：

    Treatment performed at another hospital：

    Surgery：

    Year：
    Location：

    Anti-aging：

    Regenerative Medicine：

    When did the receive the treatment?

    Treatment：

    Where was the treated?
    Country： Other
    Area：
    Clinic Name：

    Please provide details about your stem cell therapy (if applicable)
    Administration method：
    Injection site：
    Number of administrations： times
    Number of cells administered：
    Effectiveness：

    Pain treatment：


    Other：

    Data from Other Hospitals：


    If you have medical records from another hospital, please upload them here.
    Attachment file：

    Other：

    Illness under treatment：

    Treatment of infectious diseases：
    If yes, which of the following infectious diseases are you being treated for? (Select all that apply)

    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：
    Blood thinning supplements：
    Hypertension medications：
    Diabetes medications：
    Female hormone therapy：
    Psychiatric medications：
    Others：

    Medical History
    Allergies：
    Food：
    Medication：

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

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

    Emergency Contact：



    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.

    How did you hear about our clinic?

    If you select other, please specify how you found out about the clinic.

    Thank you very much for your cooperation.