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Medical Evaluation Form – Neurological diseases

Medical Evaluation Form - Neurological diseases

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.

  • Please explain your history of treatment and the results of those treatments (including different medications and alternative treatments):

  • 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.)

  • Please list any actions or chores that you are unable to carry out:

  • Medications

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

  • Results of medical examinations (MRI, CT, X-Ray, EMG, ECG, EEG, 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 have any infection, wounds or other problems with your lumbar area?

  • 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?

  • Are you suffering from severe depression or cognitive impairment?

  • Do you have active seizure disorder or are you taking anti-epileptic medications as seizure prophylaxis?

  • Are you having a current treatment with anti-coagulants (blood thinners) or apomorphine?

  • Have you ever had any treatments with immunosuppressive medications (such as systemic steroids)?

  • Have you ever had any treatments before with phenol, botulinum toxin, baclofen, or any other interventional therapies for spasticity or dystonia?

  • Do you have other diseases, previous therapies or any information that you think may be relevant for the evaluation?