Stem Cell Therapy Patient Application 2018-08-09T20:10:50+00:00

Stem Cell Institute, Panama provides stem cell therapy under IRB-approved clinical protocols for subjects with conditions including Autism, Cerebral Palsy, Degenerative Joint Disease, Heart Failure, Multiple Sclerosis, Osteoarthritis, Rheumatoid Arthritis and Spinal Cord Injury.

Please fill out the application below and submit to us online. If you cannot complete this online application and need a paper form, please call us at 1-800-980-STEM (7836) to request an application in MS Word format.

Si desea llenar nuestra aplicación en español, por favor acceda a este vínculo. Application Espanol

These procedures are not covered by most insurance and will require travel outside the US and Canada.


We DO NOT treat:

  • ALS
  • Alzheimer’s
  • Duchenne’s Muscular Dystrophy
  • Parkinson’s
  • Stroke

 

Personal Information

Clinic Location :
Were you referred?
Referred by whom? How did you first learn
about us?*
Salutation* :
Legal First Name (as on license or passport)* :
Legal Middle Name (as on license or passport) :
Legal Last Name (as on license or passport)* :
Date of Birth* :
Weight (pounds)* :
Height* :
Gender* :
Address* :
City* :
State or Province :
Zip or Country Code:
Country* :
Time Zone* :

 

One of our physicians might need to speak with you (or the applicant’s representative) personally. Please list the single best phone number to reach you, Monday – Friday 10 AM – 7PM, Central Standard Time (international, GMT – 6).

Best Phone* : (include area code)
Work Phone : (include area code)
Cell Phone : (include area code)
FAX Number: (include area code)
Email* :
Occupation:
Marital Status*:

Parent/Guardian Information

Name :
Address :
Home Phone : (include area code)
Office Phone: (include area code)
Cell Phone: (include area code)
Alternate Phone: (include area code)

Physical Limitations

*Need Assistance Walking? Yes No
*Wheel Chair Needed? Yes No
Other Needs :

Emergency Contact

Name* :
Relationship* :
Phone* : (include area code)
Address:
City:
State or Province:
Zip or Country Code:
Country:

Primary Diagnosis/Disease

Physician Name* :
Physician Phone: (include area code)
Primary Disease Diagnosis* :
Brief Description of Symptoms* :
Date of Diagnosis* :
Medical Records Available?
Medications Now On:
Anticoagulated?
Anticoagulated Since When:
Why Anticoagulated?

Subject History: Cancer

*Have you ever been diagnosed with any type of cancer? Yes No
Cancer Type:
Date Cancer Diagnosed:
Cancer Status:

Subject History: Diabetes

Are You Diabetic?
Taking Insulin?

Subject History: Neurological System

Vision Decrease?
Vision Black Spots?
Vision Nistagmus?
Muscle Weakness?
Muscle Wasting?
Walking Difficulties?
Decreased Hand Strength?
Fainting?
Speech Problems?
Tingling Sensation?
Muscle Fasciculations?
Spasticity?
Hyperreflexia?
Hyporeflexia?
Depression?
Loss of Memory?
Headaches?
Sleep Disturbances?
Dizziness?

Subject History: Pulmonary System

Asthma?
Chronic Bronchitis?
Chronic Cough?
Emphysema?
Tuberculosis?

Subject History: Cardiovascular Problems

Myocardial Infarction?
Myocardial Infarction Date:
Angina Pectoris?
Tachycardia?
By-Pass Surgery?
By-Pass Surgery Date:
Hypertension (high blood pressure)?
Hypotension (low blood pressure)?

Subject History: Circulatory

Poor Arterial Circulation?
Poor Venous Circulation?
Leg Cramps?
Tired Legs?
Swollen Ankles?
Varicose Veins?
Tingling Sensation in Arms and Legs?
Falling Asleep of the Hands and Legs?
*Ulcers or open wounds anywhere on your body? Yes No

Subject History: Gastrointestinal Problems

Acid Indigestion?
Bloating?
Stomach or Duodenal Ulcer?
Stomach or Duodenal Ulcer Date:
Loss of Appetite?
Rapid Weight Gain?
Rapid Weight Loss?
Overweight Problem?
Have You Had Upper GI endoscopy?
Upper GI Date:
Upper GI Results:
Hepatitis?
Hepatitis Type:
Gall Bladder Problems?
Gall Stones?
Icterus?
Recurring Diarrhea?

Subject History: Upper Respiratory Test

*Chronic Sinusitis? Yes No
*Allergic Sinus Problem? Yes No
*Chronic Allergic Rhinitis? Yes No
*Sinus Headaches? Yes No
*Chronic Nose Bleeds? Yes No
*Chronic Colds? Yes No

Subject History: Rheumatic Screen

Soft Tissue Rheumatism?
Articular Rheumatism?
Joint Pain?
Back Pain?
Rheumatoid Arthritis?
Other Rheumatic Conditions:

Subject History: Endocrinological System

Diabetes Mellitus?
Overactive Thyroid?
Underactive Thyroid?
Adrenal Gland Dysfunction?
Female Menopause?
Male Menopause?
Other Endocrinological Conditions:

Health History Allergy:

*Food Allergy, Especially Eggs? Yes No
*Hay Fever? Yes No
*Allergic Asthma? Yes No
*Medication Allergies? Yes No
Medication Allergy Symptoms:
*Allergies to any vaccinations? Yes No

Subject History: Other

When was your last vaccination?
*Do You Smoke Cigarettes? Yes No
*Do You Smoke Cigars? Yes No
*Do You Smoke Pipes? Yes No
How Much Do You Smoke Per Day?
*Do you drink wine? Yes No
*Do you drink beer? Yes No
*Do you drink hard liquor? Yes No
How much do you typically drink per day?
*Please list any nutritional supplements you are taking:
*Other Significant or Chronic Illnesses :
Do You Take Human Growth Hormone?
How Long Have You Taken Growth Hormone?
Human Growth Hormone Injections per Week:
PSA Test (Men Only)?
PSA Test Date:
PSA Test Result:
Periodic Mammograms

(Women only)?

Mammogram Test Date:
Mammogram test result:

Surgical/Hospitalizations

Surgical Procedure 1:
Surgical Procedure 1 Date:
Surgical Procedure 2:
Surgical Procedure 2 Date:
Surgical Procedure 3:
Surgical Procedure 3 Date:
Other Surgical Procedures:

Family History

Has any member of your family had any of the following:
Hypoglycemia?
Diabetes?
Thyroid Problem?
Hormone Problem?
Cancer?
High Blood Pressure?
Kidney Problem?
Heart Problem?
Leukemia?
Arthritis?
Prostate Problem?
Mental Disorder?
Anxiety?
Lung Problem?
Fatigue?
Stroke?
Do you have any questions or comments?:
  1. By clicking “Submit” I attest that all information I have provided on this form is accurate and complete.
  2. I understand that inaccurate or incomplete information may result in denial of treatment.
  3. Processing may take up to a minute.
  4. A new web page will load to confirm receipt of your application.
  5. After you click the Submit button, please do not reload this page or click your browser’s back button.