Medical History Form

Date

Full Name

First NameLast Name

Height

Weight

Age

Gender

MaleFemale

Birth Date

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

example@example.com

Phone Number

Emergency Contact

First NameLast Name

Phone Number

Please enter a valid phone number.

Autoimmune

Cardiovascular

Pulmonary

Orthopedic

Neurological

Autism

Facial Rejuvenation

Fertility

Sexual Wellness

Healthy Aging

Please provide diagnosis outcome

Date of Last Appointment

Description of Condition

Please describe your condition in detail.

Please provide a detailed explanation as to why you are seeking Stem Cell Treatment.

Check the symptoms that you're currently experiencing:

Symptom Frequency

DailyWeeklyMonthlyAnnually

Do you feel excessive shyness or inferior to others?

YesNo

Please rate your pain level on a scale of 1-10

Please rate how much your condition affects your life on a scale of 1-10

Are you currently taking any medication?

YesNo

If yes, please list all of your medications, vitamins, and supplements that you are currently taking. Assure to include frequency and dosage.

Have you received stem cell treatment in the past?

YesNo

If yes, please list the provider, location, and date of treatment.

Have you ever received exosome or PRP treatment in the past?

YesNo

If yes, please provide the date and location of treatment.

Do you have any known allergies?

YesNoNot Sure

If yes, please list allergy and reaction.

Please check the boxes indicating issues you've experienced.

If you have selected yes to any of the conditions above, please provide date of diagnosis and any relevant details for our medical team.

Have you had any surgeries in the past?

YesNo

Please describe any other relevant health information not discussed on this form.

Preferred Consultation Call Time

PATIENT PRIVACY: The information provided in this form is to be filled out by the patient or legal representative. By submitting this form, you authorize the release of your protected health information (PHI) to us, including Go Fillers Tijuana, and to a third party or another affiliated healthcare provider such as an insurance company, other medical professionals, medical imaging clinics, medical analysis clinics, employers, or for legal or billing purposes as may be required. This authorization will expire 1 year from the date of submission. You may revoke this authorization at any time by providing a written notice of revocation.

By selecting this option and submitting this form, I understand and agree to the Patient Privacy Statement, and I authorize the ongoing exchange of information between Go Fillers Tijuana and any and all required parties until this authorization expires or is revoked.

Referred by:

Go Fillers Tijuana Medical History Form

Treatment Menu

Diagnosis

Treatment Notes

Medication

ALLERGIES

MEDICAL HISTORY

RELEASE OF PATIENT RECORDS

Thank you!!