Date of Entry：
Your Information Name Gender Male Female Date of Birth ( years old) Nationality
Height cm Weight kg
Address Phone Number Email Address
Concerns you want to improve Pain Diabete Liver function Kidney function Sexual function Beauty (skin/hair growth) Prevention of cognitive decline Other
Treatment performed at another hospital Surgery Yes No Year Location
Anti-aging Yes No Fillers Botox Peeling Thread lift Laser Liposuction
Regenerative Medicine Yes No When did the receive the treatment? Treatment PRP APS FGF ACRS Supernatant fluid treatment Stem cell therapy Where was the treated? Country —Please choose an option— Dubai(UAE) Korea Malaysia Mexico Thailand Ukraine Japan Other Other Area Clinic Name
Please provide details about your stem cell therapy (if applicable) Administration method IV infusion local injection Injection site Number of administrations times Number of cells administered Effectiveness —Please choose an option— Good Poor No Change
Pain treatment Yes No Chiropractic Acupuncture Massage Injection Other：
Data from Other Hospitals Yes No Medical Certificate Treatment Progress Record Blood Test Results X-ray CT Scan MRI PET Scan Surgical Record Radiation Therapy Record Chemotherapy Record If you have medical records from another hospital, please upload them here. Attachment file
Other
Illness under treatment None High blood pressure Diabetes Liver disorder Kidney disorder Heart disease Cerebral Hemorrhage/Cerebral infarction Asthma/COPD Immune disease Malignant tumor Mental disease Infertility Treatment of infectious diseases Yes No 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) Tuberculosis Syphilis HIV/AIDS HTLV−1
Current Medications/Supplements Blood thinners Yes No Blood thinning supplements Yes No Hypertension medications Yes No Diabetes medications Yes No Female hormone therapy Yes No Psychiatric medications Yes No Others
Social History Alcohol Do not drink Drink ( —Please choose an option— 1 cup of sake 1 large bottle of beer 2/3 cup of shochu/awamori 1 double shot of whiskey 1/3 bottle of wine Drink more than this amount ) Tobacco Do not smoke Smoke ( cigarettes/day )
Medical History Allergies Food None Kiwi Banana Avocado Papaya Mango Melon Fig Cherry Egg Soy Wheat Peanuts Blue fish (e.g., mackerel, sardine) Other If you selected "Other," please specify the food. Severity of Allergic Reaction Mild Moderate Severe Medication None Aspirin (e.g., Bufferin) Ibuprofen (e.g., Brufen, Eve) Loxoprofen (e.g., Loxonin) Anesthetics (e.g., Xylocaine) Other If you selected "Other," please specify the medication. Severity of Allergic Reaction Mild Moderate Severe Antibiotics/Antifungals None Penicillin antibiotics Cephalosporins (e.g., Cefzon) Streptomycin Amikacin Aminoglycosides (excluding streptomycin, amikacin) Amphotericin B Other If you selected "Other," please specify the medication. Severity of Allergic Reaction Mild Moderate Severe Other None Latex Alcohol Iodine Severity of Allergic Reaction Mild Moderate Severe
Have you ever felt sick from anesthesia such as dental anesthesia (xylocaine) or gastroscopy? Yes No Are you pregnant or at risk of pregnancy (miscarriage or bortion within the last 3 months)? Yes No
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 appointment Ask about consultation and treatment Inquire about fees and payment Ask about other matters Need immediate treatment
How did you hear about our clinic? Friend's referral Agent's referral Attended seminar Saw website Instagram Facebook WeChat Other If you select other, please specify how you found out about the clinic, and It would be helpful if you could provide the name of friend or agent who referred you.
