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COMPLEMENTARY THERAPIES
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About Us
Conditions
COMPLEMENTARY THERAPIES
FAQ
Contact us

Medical Intake Form

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Diseño

Name *

Email *

Height

Date of birth: *

Phone Number *

Weight

Diseño

o Medical History:

o Surgeries

o Pharmaceutical Medications

o Treatments

o Family History

o Supplements

Diet and approximate time of each

Diseño

o Breakfast

o Lunch

o Snack

o Dinner

o Allergies

Diseño

Water (number of glasses per day):

Smoke (how many per day)

Caffeinated (how many per day)

Alcohol (how many per day)

Diseño

Exercise (if yes, how often and for how long)

Sleep (what time to what time, quality)

Bowel Movement (how often, shape, color)

Energy Level (on scale of 1-10 on average)

Diseño

Marital Status

Religion/ Higher Power

Work Type

Goals

Stress (on scale of 1-10 average)

Please be advised that all Information remains confidential and for internal use of Stem Cell Healing Institute (SCHI) only

About Us

«My Heart And Soul Sing When We See What An Incredible Impact We Can Make On The Lives Of Our Patients And Their Families With Our Natural And Comprehensive Stem Cell Therapies.»

Dr. Zahra Figueredo.

info@stemcellhealinginstitute.com

+502 4220 7297

Our treatments

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