Medical History Questionnaire

Please be sure to include details about current medications, limitation to your activities of daily living and information on any past or present physical or speech therapies. Also, it is important to mention that your records and any information about your condition or the treatments you seek or have had cannot be discussed with anyone not mentioned in this form. (download a PDF version)



About The Patient

Food Allergy(ies)

General Information

Disclaimer: Stem cell therapy is still undergoing clinical trials around the world. Although it has shown very promising results for many indications, each patient may respond differently to stem cell therapy, and there is no guarantee or warranty in any manner as to the results an individual patient may obtain. There have been no reported negative events in the use of Stemedica's stem cells in any clinical trial, and it has not been reported to be harmful or dangerous when used in dosages administered by this medical staff. A staff physician will review each patient's medical history and determine if that patient is a candidate for stem cell therapy.

Am I a Candidate?

Find Out if You Qualify