Scribd Logo
Upload

Welcome to Scribd!

  • 27 views

    Patient Evaluation Form - Cerebral Palsy: Click or Use The TAB Key To Move Between Fields

    Uploaded by

    Syed Ali Shah
    For office use only Regenecell Patient Evaluation Form - Cerebral Palsy Click or use the TAB key to move between fields. Please describe your ability to move by choosing the number in the list below which best describes you.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Patient Evaluation Form - Cerebral Palsy: Click or Use The TAB Key To Move Between Fields

    Uploaded by

    Syed Ali Shah
    27 views7 pages
    For office use only Regenecell Patient Evaluation Form - Cerebral Palsy Click or use the TAB key to move between fields. Please describe your ability to move by choosing the number in the list below which best describes you.

    Original Title

    Patient_Evaluation_Form_Cerebral_Palsy

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    For office use only Regenecell Patient Evaluation Form - Cerebral Palsy Click or use the TAB key to move between fields. Please describe your ability to move by choosing the number in the list below which best describes you.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    27 views7 pages

    Patient Evaluation Form - Cerebral Palsy: Click or Use The TAB Key To Move Between Fields

    Uploaded by

    Syed Ali Shah
    For office use only Regenecell Patient Evaluation Form - Cerebral Palsy Click or use the TAB key to move between fields. Please describe your ability to move by choosing the number in the list below which best describes you.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 7

    For office use only

    Regenecell Patient Folder No. _________________

    Patient Evaluation Form – Cerebral Palsy


    Click or use the TAB key to move between fields

    Full Name

    Date of Birth

    Occupation

    Gender Male Female

    Physical Address

    Postal Address

    Zip/Postal Code

    Tel No.

    Cellphone

    Email

    Re-enter email

    Skype user name

    © Regenecell 2007 Application Form Page 1 of 7


    Your Personal Doctor

    Name

    Telephone

    Fax

    Email

    Contact in an emergency while at the clinic (caregiver, close friend or relative)

    Name

    Tel no.

    Medical history:

    Disease for which you


    are seeking treatment

    Date
    Other Diagnoses

    What events lead up to you being diagnosed with this disease?

    History of events after diagnosis

    © Regenecell 2007 Application Form Page 2 of 7


    How would you
    describe your current
    condition?

    Your Height Your Weight

    Yes No
    Have you experienced sudden weight loss (above 5kg)?

    Do you have, or have you suffered from:


    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

    © Regenecell 2007 Application Form Page 3 of 7


    Menopause
    HIV/AIDS
    Cancer
    Surgery
    Are you on?
    Chemotherapy
    Anticoagulants
    Antibiotics
    Steroids

    Signs
    Mild Moderate Severe
    Spasticity

    Scissoring

    Clonus

    Fixed joints

    Painful spasms

    Higher functions affected

    Medication

    Name Dose Strength Date Started Date Stopped

    © Regenecell 2007 Application Form Page 4 of 7


    Smoking

    Amount per day

    When started

    When stopped

    Alcohol
    Type Amount per day/week

    Family history of disease:

    Disease Mother Father Grandmother Grandfather Brother Sister

    Supplementation

    List all nutritional supplements – please include brand names.

    © Regenecell 2007 Application Form Page 5 of 7


    Expectations

    What do you expect to achieve from the treatment?

    Yes No
    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.

    Enter the number 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.

    © Regenecell 2007 Application Form Page 6 of 7


    Please include a MRI report.

    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

    Return this form as an attachment to [email protected]

    Or

    By Fax: + 27 86 503 2563

    From the UK: 0027 86 503 2563


    From the USA: 01127 86 503 2563

    © Regenecell 2007 Application Form Page 7 of 7

    You might also like