AnmeldebogenEN

1. GENERAL DATA

Surname patient *

First name patient *

Sex patient male female *

Date of birth patient *

Nationality *

Address *

Postal code *

City *

Country *

Phone number *

E-mail address *

2. MIS FILE (medical information sheet)

Diagnosis

Main symptomatology, patient history with symptoms

Allergies

Blood group

Height

Weight (kg)

Medication

Previous medical findings

Assistive technology

Operative procedures so far

Nutritional needs

3. REQUIREMENTS FOR TREATMENT OF STEM CELLS

3.1 MRT Magnetic resonance tomography of the brain and spine (Neurological disease)

3.2 Recent blood lab values
(red and white BC, coagulation, hepatitis, blood group, blood sugar, Hba1c)
- not older than two weeks before arrival here.

3.3 Neurological status for neurological disease

3.4 blood group identitiy card

3.5. all relevant medical data and medical documentation so far

I fulfill the requirements yes no *

Explanation *

4. EXCLUSION CRITERIA FOR TREATMENT SCT

Coagulation disorders
Carcinoma in the last five years or
current cancer disease
Age: less than 6 months, over 80 years
artificial respiration
unconsciousness
dialysis
cachexia
pronounced anemia
Respiratory and cardiovascular diseases or other conditions that justify the risk of general anesthesia or not allow
acute infection, fever
muscle dystrophy aged over 20 years
genetic metabolic diseases

Exclusion criteria exist yes no *

What exclusion criteria *

5. TRANSPORTABILITY

Transport sitting lying *

How many accompanying persons *

6. SPECIFY PAYMENT AGB Wiener Privatklinik

Payment Bank transfer
Card payment
Cash
*

Special diets required or asked for *

Long-term medication *

Security

I accept evaluation of my data submitted *

7. YOUR DATA HAS BEEN SUCCESSFULLY SENT.

Thank you.