Parkinson�s Disease Patient Evaluation Form
Personal Information
Name
Surname
Date of Birth
Occupation
Gender
Physical Address
 
 
Country
Postal Address
 
Zip/Postal Code
Tel No.
Mobile No.
Email
Confirm Email
Skype Username
Your Personal Doctor
Name
Tel
Fax
Email
Contact in an emergency while at the clinic (caregiver, close friend or relative)
Name
Tel
Medical History
Disease for which you are seeking treatment
Date of first diagnosis
Other Diagnosis / Date
 
/
 
/
 
/
 
/
What events lead up to you being diagnosed with this disease?
History of events after diagnosis
How would you describe your current condition?
Height / Weight
/
Have you experienced sudden weight loss (above 5kg)?
Do you have, or have you suffered from:
Conditions Yes / No If 'Yes' please elaborate
Allergies: food, vaccination, drugs, hayfever
Heart problems
High blood pressure
Asthma
Lung disease
Epilepsy
Psychiatric problems � nervousness, depression
Gastrointestinal problems
Liver problems
Hepatitis type: A
Hepatitis type: B
Hepatitis type: C
Renal problems
Kidney infections
Musculoskeletal problems
Osteoporosis
Osteoarthritis
Rheumatoid arthritis
Blood disorder
Thrombosis
Diabetes type 1
Diabetes type 2
Thyroid disorder
Overactive
Underactive
Menopause
HIV/AIDS
Cancer
Surgery
Are you on?
Chemotherapy
Anticoagulants
Antibiotics
Steroids
Medication
Name Dose Strength Date Started Date Stopped
Do you smoke
Amount per day
When started
When stopped
Do you drink alcohol
Type / Amount per day
/
Type / Amount per day
/
Family History of Disease
Disease Mother Father Grandmother Grandfather Sister Brother
Supplementation
List all nutritional supplements � please include brand names.
Previous Stem Cell Treatment
Have you had Stem Cell Treatment before
What kind of cells did you receive?
How many cells did you receive?
Expectations
What do you expect to achieve from the treatment?
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 and enter it 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.
Parkinson�s Disease
Do you have any of the following symptoms?
Symptoms Yes / No If 'Yes' please elaborate
Tremor
Slowness of movement
Rigidity (stiffness)
Difficulty with balance
Small, cramped handwriting
Stiff facial expression, unblinking
Shuffling walk
Muffled, monotonous speech
Depression
Increased salivation and dribbling
Confusion
Dementia
Memory loss
Incontinence urine and/or bowel
Able to take care of self
How did you hear about Regenecell?
Internet Search
Personal Referral
By Whom?
Other
Details:

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: