Diabetes type 1. Diabetes type 2. Thyroid disorder. Overactive Is your diabetes controlled? Do you have symptoms of: Yes No. Thirst. Increased fluid intake …

Patient Evaluation Form - Diabetes Type 2

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Full Name

Date of Birth

Occupation

Gender Male Female

Physical Address

Country

Postal Address

Zip/Postal Code

Tel No

Cellphone

Re-enter email

Skype user name

Your Personal Doctor

Name

Telephone

Fax

Contact in an emergency while at the clinic caregiver, close friend or
relative

Name

Tel no

Medical history:

Disease for which you
are seeking treatment

Date of first diagnosis

Date
Other Diagnoses

What events lead up to you being diagnosed with this disease?

History of events after diagnosis

How would you describe your current condition?

Your Height

Yes No
Have you experienced sudden weight loss above 5kg?

Medication

Name Dose Strength Date
Started Date Stopped

Smoking

Amount per day

When started

When stopped

Alcohol
Type Amount per day/week

Family history of disease:

Supplementation

List all nutritional supplements - please include brand names

Previous Stem Cell Therapy

Yes No
Have you had stem cell treatment before?

If
Yes

What kind of cells did you receive?

How many cells did you receive?
Expectations

What do you expect to achieve from the treatment?

Yes No
You understand that this is a treatment and not a cure?

Mobility Assessment

Please describe your ability to move by choosing a number in the list below
which best describes you

Enter the number here:

0 Asymptomatic; fully active

1 Walks normally, but reports fatigue that interferes with athletic or
other demanding activities

2 Abnormal gait or episodic imbalance; gait disorder is noticed by
family and friends; able to walk 25 feet 8 meters in 10 seconds or
less

3 Walks independently; able to walk 25 feet in 20 seconds or less

4 Requires unilateral support cane or single crutch to walk; walks 25
feet in 20 seconds or less

5 Requires bilateral support canes, crutches, or walker and walks 25
feet in 25 seconds or less; or requires unilateral support but needs
more than 20 seconds to walk 25 feet

6 Requires bilateral support and more than 20 seconds to walk 25 feet;
may use wheelchair on occasion

7
Walking limited to several steps with bilateral support; unable to
walk 25 feet; may use wheelchair for most activities

8 Restricted to wheelchair; able to transfer self independently

9 Restricted to wheelchair; unable to transfer self independently

Diabetes

Presently we only accept Type 2 Diabetics

Yes No
Is your diabetes controlled?

What is your most recent Hba1c?

Result

Date

Yes No
Are you compliant with your diet?

Do you have any of the following complications:

Please supply reports from the specialists involved

How
did you hear about Regenecell?

I understand that Regenecell Stem Cell Therapy is not a US FDA-approved
procedure and is in no way to be construed or presented as a cure for any
condition, degenerative disease or injury, and clinical benefits from this
therapy cannot be guaranteed

I accept the above

Return this form as an attachment to info@regenecellcom

By Fax: 27 86 503 2563

From the UK: 00 27 86 503 2563
From the USA: 011 27 86 503 2563

———————–
For office use only

Regenecell Patient Folder No _________________

Your Weight

Source:regenecell.com