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Medical Evaluation Form

Thank you for your interest in our service.


In order for our medical team to evaluate whether or not you are eligible for treatment and recommend a relevant medical program and treatment for you, please fill in the form below to the best of your ability or with the help of your physician.

  • Name *

  • Date of Birth *

  • Country

  • Email *

  • Phone

  • Height

  • Unit

  • Weight

  • Unit

  • History and Diagnosis

  • What is your Primary diagnosis? *

  • When were you first diagnosed?

    MM

    DD

    YYYY

    If you don't remember the specific date, just fill in the year of diagnoses with or without month.

  • Please describe the progression of your condition from early symptoms until now.

  • Have you taken any therapies before? If yes, what’s the program? (Medication, dosage and period, etc.)

  • Does anyone in your family have medical history relevant to your condition?

  • Symptoms

  • Please list all of your current symptoms: (mobility, performance of daily activities, speech, breathing, eating, metabolism, mental and emotional condition, etc.)

  • Medications

  • Please list any medications that you are currently taking with dosage and effectiveness and / or side effects

  • Results of medical examinations (blood tests, chemistry examinations and radiology examinations, etc.)

  • Please list the diagnostic exams you have had along with date, results and if images are available on request.

    Any medical records that you can send us will be helpful for your medical evaluation.

    If possible, please attach to the form below any or all of the following:

    MRI / CT images (on CD, Film, or via email)

    Medical records or recent neurological evaluation from your neurologist

    Video: a short video (3-5 minutes) showing the patient performing simple daily activities. You may use a simple home camera to prepare this video and send us via email or on a CD.

  • File

  • File

  • File

  • File

  • File

  • Hypertension

  • Heart disease

  • Pneumonia

  • Diabetes

  • Hyperlipidemia

  • CVA/ Stroke

  • Lung disease

  • Liver disease

  • Kidney disease

  • Fracture or break

  • Cutaneous basal cell carcinoma or in situ carcinoma

  • Cancer or tumor

  • Inflammation or infection

  • Others

  • Other information

  • Is there a caregiver who can provide you with care and assistance during your stay at the hospital if necessary?

  • Do you smoke?

  • Are you currently using or ever used drugs or alcohol?

  • Do you have sleep apnea, chronic obstructive pulmonary disease or other condition that doesn't allow for general anesthesia?