Patient Evaluation Form

Dear Patient, we thank for your interest on Stem Cell Treatment at Revita Life Sciences. To evaluate your case we need to have the following information. This will help our specialised doctors to determine and understand the medical condition that could help us in improving your quality of life. If possible, please attach previous lab studies, medical reports or any documents into an e-mail and send it to info@revitalife.co.in with contact details.

Date:

Full Name *

Age:

Email *

Phone Number:

Best time / day to contact:

Religion:

Gender

Male
Female

Marital Status:

Weight:

Height:

Place of Birth:

Residence (City, country):

Do you smoke?

Amount / Frequency you smoke:

Do you use any drugs?

What / Frequency you use drug:

Have any allergies?

Type of allergies you have:

Any special diet?

Explain your special diet:

Do you drink?

Drinks per week:

Practice any sport?

Type / Frequency of your sport:

Allergies to any medicine?

Which allergies to any medicine:

Diagnostic:

First Symptom Date:

Diagnostic Date:

Initial Symptoms:

Available Lab Studies:

Available X-Rays:

Treatments received on the past:

Current Symptoms:

Other Illness present:

Current Medication:

Previous Surgeries: (explain cause and date):

Special Requirements:

Additional comments / questions:

Number of pregnancies:

Vaginal births:

C-sections:

Abortions:

Menopause:

Using hormone therapy:

The website contains no medical advice. All statements and opinions provided by the website are for educational and informational purposes. ||The treatment centres associated with Revita lifesciences provide surgical procedure only and are not involved in use or manufacture of any investigational drug ||Revita does not claim that any application or potential application, using autologous stem cells are approved by the FDA. We do not claim that these procedures work for any listed nor unlisted condition, intended or implied.||It’s important for potential patients to do their own research based on the options we present so that one can make an informed decision. Any decision to participate in experimental protocol is completely voluntary ||

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