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HOME
About Us
About Stem Cells
Stem Cell Treatments
Complementary Treatment
Contact Us
F.A.Q.

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Patient Application

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

Personal Information

Where you referred?

Gender

Male Female

Marital Status

single married

Need Assistance

Wheel Chair Needed?

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Medical Records

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Anticoagulated?

Yes No

Have you ever been diagnosed with any type of cancer?

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Are you Diabetic

Yes No

Taking Insulin?

Yes No

Check all that applies

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

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Asthma Chronic Bronchitis Chronic Cough Emphysema Tuberculosis

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

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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

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

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Chronic Sinusitis Allergic Sinus Problem Chronic Allergic Rhinitis Sinus Headaches Chronic Nose Bleeds Chronic Colds

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Soft Tissue Rheumatism Articular Rheumatism Joint Pain Back Pain Rheumatoid Arthritis

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Diabetes Mellitus Overactive Thyroid Underactive Thyroid Adrenal Gland Dysfunction Female Menopause Male Menopause

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Food Allergies, specially eggs Hay Fever Allergic Asthma Medication Allergies Allergies to any vaccinations

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Do you Smoke Cigarettes Do you Smoke Cigars Do you Smoke Pipes Do you Drink Wine Do you Drink Beer Do you Drink Hard Liquor Do you Take Nutritional Supplements Do you Take Growth Hormones PSA test (men only) Periodic Mammograms (women only)

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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

stem cell healing institute

Visit us, or set an appointment. We look forward to help restore your health.

Blvd Vista Hermosa 5-19 zona 15 Nivel 12 oficina 1202, Guatemala City Guatemala 01015

info@stemcellhealinginstitute.com

+1 209-690-7836
+502 4220-7297
Open 24/7

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