PATIENT MEDICAL FORM

Advanced Mesenchymal Stem Cell therapy

Experiencing the Efficacy of MSCs: Undergo our groundbreaking treatment protocol in Antigua and Barbuda, built on over thirty years of pioneering experience in the clinical application of stem cells, using culture-expanded mesenchymal stem cells derived from umbilical cord tissue and manufactured in a GMP-compliant laboratory.
In order for our specialists to evaluate your case, please fill out our Medical History Form:

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We'd love to hear from you! Please fill out the form and we'll get back to you as soon as possible.

First Name*

Last Name*

Date of birthday*

MM slash DD slash YYYY

Age

Gender*

Height

Weight*

Marital Status

Address

Street Address City State / Province ZIP / Postal Code Country

Time zone

Mobile phone number*

WhatsApp phone number

Consent

Do you want us to call back?

Email*

Occupation

Parent/Guardian Information/Emergency contact

Name

Relationship

Mobile phone number

How did you hear about us?

Consent*

Check the box if you understand that this is a patient-funded program, and the treatment cost starts from $____ USD. Please note that travel is not included in this amount. *

Consent*

Check the box if you understant that EmCell Stem Cell Center is located in Jolly Harbour, Antigua and Barbuda. To ensure a smooth and successful experience, you must be physically, mentally, and legally able to travel to our clinic. If you have mobility challenges, a companion will be required to assist you during your journey. *

Primary Condition

Primary condition for which you seek treatment *

Primary condition for which you seek treatment*

Diagnosis date

MM slash DD slash YYYY

Describe all symptoms, dates of onset, and any other pertinent information *

Describe all symptoms, dates of onset, and any other pertinent information*

Have you received a stem cell treatment before?

What do you intend to achieve with the treatment you are seeking?

Past Medical History

Which of the following conditions is currently being treated or has been treated in the past? (check the appropriate variant or variants):

Appropriate variant or variants

Are you Diabeitc?

Taking Insulin?

Do you have infectious diseases?‎

Did you have surgery/injuries?‎

Please, provide the details here

Have you had or been diagnosed with any type of cancer within the past two years?*

Type of Cancer*

Date of diagnosis*

MM slash DD slash YYYY

Cancer status*

Describe any current or past medical conditions not included in the above list

Have you ever been hospitalized?*

Why was hospitalization necessary?*

Current Medication

Please list your allergies

Severe allergies or anaphylaxis to medications or infusions?*

Which medication or infusion

Nutritional supplements / Herbal preparations

Please list your current medications

Anticoagulated?

Anticoagulated since when?

Did you get vaccinated in the last 6 months?

Which vaccine did you take?

When did you get vaccinated?

Social and Preventive History

Do you currently smoke or chew tobacco?

Do you drink alcohol, beer or wine?

Consent*

I declare that all medical information provided on this form is true and complete to the best of my knowledge. I understand that any omission or misrepresentation in my medical history may interfere with the proper evaluation and success of treatment. I agree that, in the event of failure to disclose relevant medical conditions, I assume responsibility and any associated risks, including contraindications or adverse effects resulting from the procedure. *

Symptom Check

Do you currently have any of the following symptoms? Check all that apply:

Eyes, Ears, Nose, Throat

Blurry vision

Another change in vision

Hearing loss

Ringing in the ears

Sinus problems

Hoarseness

Nosebleeds

Muscle, Joint, Bone

Swollen ankles or legs

Weakness or numbness in:

Arms or hands

Hips

Legs or feet

Muscle pain in:

Neck or shoulders

Back pain

Joint pain

Pulmonary

Breathing difficulty

Persistent cough

Coughing up blood

Wheezing

Neurological

Blackouts or loss of consciousness

Bad sleep

Headaches

Dizziness

Memory loss

Speech problems

Cardiovascular

Chest pain

Irregular heartbeat / Tachycardia

History of poor circulation

History of angina or heart attack

Hypertentsion (high blood preasure)

Hypotension (low blood preasure)

Genitourinary

Frequent or painful urination

Blood in the urine

Incontinence

Gastrointestinal

Little appetite

Abdominal pain

Indigestion

Swallowing difficulty

Diarrhea

Constipation

Change in bowel habits

Nausea or vomiting

Rectal bleeding or blood in the stool

Weight gain/loss of more than 10 pounds in the past 6 months

Endocrine

Change in tolerance to cold or hot temperatures

Excessive thirst

Hot flushes

Female menopause

Skin

Itching

Bruises easily

General state of health

Get tired easily

Problems with sleep

Thinking/memory become slower

Slowing down of the regenerative processes in your body

Slower metabolic processes

Sexual problems (decreased libido)

Do you need a wheelchair?

Other Requirements

Please add to the file the medical records that can support the diagnosis of our physicians

File

Drop files here or

Accepted file types: jpg, pdf, tif, docx, Max. file size: 30 MB.

EmCell Stem Cell Center is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you:

Consent*

I agree to receive other communications from EmCell Stem Cell Center. In order to provide you the content requested, we need to store and process your personal data. If you consent to us storing your personal data for this purpose, please tick the checkbox below. *

Consent*

I agree to allow EmCell Stem Cell Center to store and process my personal data. You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy. *

Consent*

I have read and agree to the Terms and Conditions*

I have read and agree to the Opens a new window Terms and Conditions. *

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Heart disease
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Liver problems
Emphysema
Arthritis
Pulmonary fibrosis
Thyroid problems
Chronic bronchitis
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