Treatment Center

Initial Adult History Form

  • Your Current Medical Condition(s)

    List the Condition(s) which bring you to our Office. Click the + to add each condition.
  • Add a new row
  • Past Hospitlizations

    List Dates of Hospitalizations and Surgeries. Click the + to add each Hospitalization and Surgery.
  • Add a new row
  • Medications

    Prescription and Non-Prescription (including Aspirin, Birth Control, Vitamins, Herbs, Supplements, etc.)
  • Add a new row
  • Allergies

  • Add a new row
  • Immunizations

  • Diagnosis

    Have you been Diagnose with any of the following.
  • Review of Systems

  • Please check all symptoms that you experience.
  • Social History

  • Energy Level

    On a scale of 1-10 with 1 being lowest, 10 being highest, please list your energy level.
  • Sleep

    (Please check what closest applies to you)
  • Stress

    (Please check all that apply)
  • Diet

  • Please Check Which Applies

  • I HAVE ANSWERED THE ABOVE ACCURATELY TO THE BEST OF MY KNOWLEDGE.

Dr. Thomas A. Gionis, MD JD
Surgeon-in-Chief
Stem Cell Research and Treatment