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*What is your height?
*What is your weight?
*What is your Main diagnosis (disease)?
*When were you first diagnosed?
*Medications currently used for your Main disease?
*Medications used in the past for your Main disease?
*Do you have (or had in the past) other co-existing diseases?
*List any other medications in use or used for co-existing diseases:
Are you allergic to anything
Do you suffer from illnesses of any of the following organs:
select all applicable answers
- Digestive System
*Describe your illness:
GP Phone Number
*Any other symptoms you would like to talk about?
*Have you been treated with Stem Cells before?
If Yes, please describe
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*Where did you hear about us?
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