1. Date of birth:
3. What is your weight, height:
4. What is your diagnosis (disease):
5. How long do you suffer from the pointed disease?
6. What kind of medications do you currently use?
7. Do you have (or had in the past) other co-existing diseases?
8. Do you suffer from illness of any of the following organs:
9. Please describe if you have any problems with: breathing, movements, speech, sleep, etc.
10. Do you need assistance performing every day activities?
11. Are you allergic to anything?
12. Have you been treated with Stem Cells before?
13. First and Last Name:
15. E-mail address