Medical History Form | Zemyna Stem Cell Clinic

Please complete and submit the following form. All of the requested information has to be provided for the Clinic to determine whether the patient can be treated with allogeneic human Umbilical Cord Blood-derived MSCs. Should you have any inquiry regarding this form, kindly contact Zemyna Stem Cell Clinic at info@zemyna.com

Patient Information

Patient Name as (listed on identification):

Date of Birth:

Gender:

Nationality:

Phone Number:

Mobile Number:

Email Address:

Home Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Doctor's Name:

Doctor's Office Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Doctor's Phone Number:

Doctor's Email Address:

Next of Kin / Emergency Contact

Name:

Email Address:

Phone Number:

Mobile Number:

Relationship to Patient:

Patient Health Information

Height (feet):

Height (centimeters):

Weight (pounds):

Weight (kilograms):

Age:

Occupation:

Current Pain Level (No pain 0, Highest pain 10):

Please select any previous medical conditions:

If "Other", please specify:

Please select medical conditions and list any family members (mother, father, sibling) below:

If "Other", please specify

etc.) Date: Occurrence

Allergy (medicine, food, diet)?

Allergy Type

Reaction

Allergy Type

Reaction

Allergy Type

Reaction

Allergy Type

Reaction

Allergy Type

Reaction

Do you take any medications?

Medication

Route (Oral, injection, etc.)

Dose

Frequency

Medication

Route (Oral, injection, etc.)

Dose

Frequency

Medication

Route (Oral, injection, etc.)

Dose

Frequency

Medication

Route (Oral, injection, etc.)

Dose

Frequency

Medication

Route (Oral, injection, etc.)

Dose

Frequency

Medication

Route (Oral, injection, etc.)

Dose

Frequency

Medication

Route (Oral, injection, etc.)

Dose

Frequency

Medication

Route (Oral, injection, etc.)

Dose

Frequency

Have you had any previous surgeries?

Surgery Type

Occurrence Date (approx.)

Surgery Type

Occurrence Date (approx.)

Surgery Type

Occurrence Date (approx.)

Surgery Type

Occurrence Date (approx.)

Surgery Type

Occurrence Date (approx.)

Social History

Do you currently smoke tobacco?

Have you smoked tobacco in the past?

How old were you when you FIRST started to smoke?

How long have you been smoking?

On the average, how many cigarettes do you now smoke a day?

Do you consume alcohol?

How many times per week do you have a drink containing alcohol?

How many ounces or milliliters of beer, wine and or spirits do you have in a typical day?

Drink Type

Beer

Milliliters

Ounces

Drink Type

Wine

Milliliters

Ounces

Drink Type

Spirits

Milliliters

Ounces

Review of System

Please indicate if you have recently had any symptoms listed below.

Sudden change in weight

Weight loss
Weight gain

How many pounds or kg?

Duration?

Digestive System

Cardiovascular System

Shortness of breath
Feel heavy in the chest when you exercise
Tightness in the chest
Shortness of breath when you lie down
Irregular pulse rate / Palpitations

Nervous System

Respiratory System

Urinary System

Other

Confirmation

I agree that I am providing my medical information and acknowledge that The Health Insurance Portability and Accountability Act (HIPAA) of the USA and Personal Information Protection and Electronic Documents Act (PIPEDA). PIPEDA of Canada is governed by the Laws of the Bahamas.

Name:

To the best of my knowledge, the above information is correct and is only for the use of Poinciana Recovery Center and Zemyna Corporation and will not be shared with others than with the staff of the clinic:

Name of Patient:

Signature of Patient:

Clear Signature

Date:

Name of Witness:

Signature of Witness:

Clear Signature

Date: