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Title Mr.Mrs.
First Name
Last name
Identification Number
Date of Birth
Zip Code
Desired First Appointment Date
Desired Treatment Assessment and ScreeningIndividualized Cell TherapyDetox ProgrammeVitalization programmeOther
Desired Accomodation SingleDoubleSuite
Have you received any cell therapy before? YesNo
If yes, when and where did you receive the cell therapy?
What is your expectations for the desired treatment?
On basic of which problems are you aiming for the desired treatment?
Customer Signature:
Date :
Medical Information
Do you take any medication? YesNo
Family medical history YesNo
Past illnesses YesNo
Have you ever had surgery? YesNo
Have you ever suffered from the following health problems? Please mark accordingly
(Please tick/ where applicable)

Low blood pressureHigh blood pressureBronchial AsthmaStrokeGeneral tirednessInsomniaExcessive need of sleepDiminution of mental efficiencyDiminution of physical efficiencyFailing memoryLack of concentrationPremature AgingStressHeadachesGiddinessMigraineDecrease of potencyTroubles of menopauseMenstruation difficultiesWeight increaseWeight decreaseOverweightConstipationDiarrheaLoss of appetiteExcess appetitePsychiatric illnessNervous disturbancesDepressionDisturbances of blood supply (night)Heart and circulation disturbances
Liver Ailments

Hepatitis, if yes, when?Jaundice, if yes, when?Gall-stones? Operated? When?

Kidney Ailments

Kidney stones? Operated? When?Nephritis (inflammation of)Nephrosis

Do you pass urine with

DifficultyTime frequencyBurning sensation


Blood glucose level
Pains in joints or limbs Other:
ShouldersBack or NeckElbowsHand jointsKneesAnkle JointsSpine column (cervical, thoracic, lumbar)

Remarks: Allergies

Customer Signature Date

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