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Cantal - Auvergne
Haute-Loire - Auvergne
Pu-de-Dme - Auvergne
Cote-dOr - Bourgogne
Nievre - Bourgogne
Saone-et-Loire - Bourgogne
Yonne - Bourgogne
Cotes-dArmor - Bretagne
Finistere - Bretagne
Ille-et-Vilaine - Bretagne
Morbihan - Bretagne
Cher - Centre
Eure-et-Loir - Centre
Indre - Centre
Indre-et-Loire - Centre
Loir-et-Cher - Centre
Loiret - Centre
Ardennes - Champagne-Ardenne
Aube - Champagne-Ardenne
Marne - Champagne-Ardenne
Haute-Marne - Champagne-Ardenne
Corse-du-Sud - Corse
Haute-Corse - Corse
Doubs - Franche-Comte
Jura - Franche-Comte
Haute-Saone - Franche-Comte
Haute-Saone - Territoire de Belfort
Paris - Ile-de-France
Seine-et-Marne - Ile-de-France
Yvelines - Ile-de-France
Essonne - Ile-de-France
Hauts-de-Seine - Ile-de-France
Seine-Saint-Denis - Ile-de-France
Val-de-Marne - Ile-de-France
Val-dOise - Ile-de-France
Alpes-de-Haute-Provence
Hautes-Alpes
Alpes-Maritimes
Bouches-du-Rhne
Var
Vaucluse
Archipel des Tubuai
Archipel des Marquises
Iles Sous-le-Vent
Archipel des Tuamotu
Iles du Vent
Ile Amsterdam
Iles Crozet
Adelie Land
Iles Kerguelen
Ile Saint-Paul
Estuaire
Haut-Ogooue
Moyen-Ogooue
Ngounie
Nyanga
Ogooue-Ivindo
Ogooue-Lolo
Ogooue-Maritime
Woleu-Ntem
Banjul
Brikama
Basse
Central River
Janjangbure
Kanifeng
Kerewan
Kuntaur
Lower River
Mansakonko
North Bank
Upper River
Western
Abkhazia
Ajaria
Guria
Imereti
Kakheti
Kvemo Kartli
Mtskheta-Mtianeti
Racha Lechkhumi and Kvemo Svaneti
Samtskhe-Javakheti
Shida Kartli
Samegrelo-Zemo Svaneti
South Ossetia
Tbilisi
Berlin
Brandenburg
Baden-Wurttemberg
Bayern
Bremen
Hessen
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Mecklenburg-Vorpommern
Niedersachsen
Nordrhein-Westfalen
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Schleswig-Holstein
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Sachsen-Anhalt
Thuringen
Ashanti Region
Brong-Ahafo Region
Central Region
Eastern Region
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Northern Region
Upper East Region
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Volta Region
Western Region
Attica
Central Macedonia
Central Greece
Crete
East Macedonia and Thrace
Epirus
Ionian Islands
North Aegean
Peloponnesos
South Aegean
Thessaly
West Greece
West Macedonia
Avannaa
Kitaa
Tunu
Saint Andrew
Carriacou
Saint David
Saint George
Saint John
Saint Mark
Saint Patrick
Petit Martinique
Saint Barthelemy
Saint Martin
Guadeloupe
Guam
Alta Verapaz
Baja Verapaz
Chimaltenango
Chiquimula
Escuintla
Guatemala
Huehuetenango
Izabal
Jalapa
Jutiapa
El Peten
El Progreso
El Quiche
Quetzaltenango
Retalhuleu
San Marcos
Solola
Santa Rosa
Sacatepequez
Suchitepequez
Totonicapan
Zacapa
Boffa
Boke
Beyla
Conakry
Coyah
Dabola
Dubreka
Dinguiraye
Dalaba
Forecariah
Fria
Faranah
Gaoual
Gueckedou
Koubia
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Kindia
Kankan
Kouroussa
Kerouane
Kissidougou
Labe
Lelouma
Lola
Mali
Mamou
Mandiana
Macenta
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Telimele
Tougue
Yomou
Biombo Region
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Pomeroon-Supenaam
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Upper Takutu-Upper Essequibo
Artibonite
Centre
GrandAnse
Nord
Nord-Est
Nord-Ouest
Ouest
Sud
Sud-Est
Flat Island
Heard Island
McDonald Island
Shag Island
Atlantida
Choluteca
Colon
Comayagua
Copan
Cortes
Francisco Morazan
Gracias a Dios
Islas de la Bahia (Bay Islands)
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El Paraiso
La Paz
Santa Barbara
Valle
Yoro
Central and Western Hong Kong Island
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Wan Chai Hong Kong Island
Kowloon City Kowloon
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Budapest
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Eger
Fejer
Gyor-Moson-Sopron
Gyor
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Hokkaido
Aomori
Iwate
Miyagi
Akita
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Ibaraki
Totigi (Tochigi)
Gunma
Saitama
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Tokyo
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Isikawa (Ishikawa)
Hukui (Fukui)
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Sizuoka (Shizuoka)
Aiti (Aichi)
Mie
Siga (Shiga)
Kyoto
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Nara
Wakayama
Tottori
Simane (Shimane)
Okayama
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Yamaguti (Yamaguchi)
Tokusima (Tokushima)
Kagawa
Ehime
Koti (Kochi)
Hukuoka (Fukuoka)
Saga
Nagasaki
Kumamoto
Oita
Miyazaki
Kagosima (Kagoshima)
Okinawa
Ajlun
Amman
Al Aqabah
Al Balqa
Irbid
Jarash
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Madaba
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Maan
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Az Zarqa
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Aqtobe
Almaty
Almaty
Astana
Atyrau
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Central
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Nyanza
Rift Valley
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Abaiang
Aranuka
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Banaba
Beru
Kanton
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Tarawa
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Hamgyong-bukto
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Rason Directly Governed City
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Pyongan-namdo
Pyongyang Special City
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Seoul Special City
Busan Metropolitan City
Daegu Metropolitan City
Incheon Metropolitan City
Gwangju Metropolitan City
Daejeon Metropolitan City
Ulsan Metropolitan City
Gyeonggi-do
Gangwon-do
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Jeollabuk-do
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Gyeongsangnam-do
Jeju-do
Kosovo
Montenegro
Serbia
Vojvodina
Al Ahmadi
Al Farwaniyah
Hawalli
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Batken
Chu
Bishkek
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Naryn
Osh
Talas
Ysyk-Kol
Attapu
Bokeo
Bolikhamxai
Champasak
Houaphan
Khammouan
Louang Namtha
Louangphabang
Oudomxai
Phongsali
Salavan
Savannakhet
Vientiane
Vientiane
Xaignabouli
Xekong
Xiangkhoang
Xaisomboun
Aizkraukles Rajons
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Cesu Rajons
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Daugavpils
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Liepaja
Liepajas Rajons
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Preilu Rajons
Riga
Rigas Rajons
Rezekne
Rezeknes Rajons
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Valmieras Rajons
Ventspils
Ventspils Rajons
Butha-Buthe
Berea
Leribe
Mafeteng
Mohales Hoek
Mokhotlong
Maseru
Qachas Nek
Quthing
Thaba-Tseka
Bong
Bomi
Grand Cape Mount
Grand Bassa
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Grand Kru
Lofa
Margibi
Maryland
Montserrado
Nimba
River Cess
Sinoe
Ajdabiya
Ash Shati
Awbari
Al Aziziyah
Banghazi
Darnah
Al Fatih
Ghadamis
Gharyan
Al Jabal al Akhdar
Al Jufrah
Al Khums
Al Kufrah
Misratah
Murzuq
An Nuqat al Khams
Sabha
Surt
Sawfajjin
Tarhunah
Tarabulus (Tripoli)
Tubruq
Yafran
Az Zawiyah
Zlitan
Schaan
Balzers
Eschen
Gamprin
Mauren
Triesen
Planken
Ruggell
Triesenberg
Vaduz
Schellenberg
Alytus
Kaunas
Klaipeda
Marijampole
Panevezys
Siauliai
Taurage
Telsiai
Utena
Vilnius
Clervaux
Diekirch
Redange
Vianden
Wiltz
Echternach
Grevenmacher
Remich
Capellen
Esch-sur-Alzette
Luxembourg
Mersch
St. Anthony Parish
Cathedral Parish
St. Lawrence Parish
St. Lazarus Parish
Our Lady Fatima Parish
Antananarivo province
Antsiranana province
Fianarantsoa province
Mahajanga province
Toliara province
Toamasina province
Balaka
Blantyre
Chikwawa
Chiradzulu
Chitipa
Dedza
Dowa
Karonga
Kasungu
Likoma
Lilongwe
Machinga
Mchinji
Mangochi
Mulanje
Mwanza
Mzimba
Nkhata Bay
Nkhotakota
Nsanje
Ntchisi
Ntcheu
Phalombe
Rumphi
Salima
Thyolo
Zomba
Johor
Kedah
Kuala Lumpur
Kelantan
Labuan
Malacca
Negeri Sembilan
Penang
Pahang
Perak
Perlis
Sabah
Selangor
Sarawak
Terengganu
Wilayah Persekutuan
Ari Atoll Dheknu
Ari Atoll Uthuru
Addu
Faadhippolhu
Felidhe Atoll
Fua Mulaku
Huvadhu Atoll Dhekunu
Huvadhu Atoll Uthuru
Hadhdhunmathi
Kolhumadulu
Male Atoll
Maalhosmadulu Dhekunu
Maalhosmadulu Uthuru
Miladhunmadulu Dhekunu
Miladhunmadulu Uthuru
Mulaku Atoll
Nilandhe Atoll Dhekunu
Nilandhe Atoll Uthuru
Thiladhunmathi Dhekunu
Thiladhunmathi Uthuru
Bamako Capital District
Gao
Kidal
Koulikoro
Kayes
Mopti
Segou
Sikasso
Tombouctou
Attard
Balzan
Birgu
Birkirkara
Bormla
Birzebbuga
Dingli
Fgura
Floriana
Fontana
Gudja
Ghajnsielem
Gharb
Ghasri
Gargur
Gaxaq
Gzira
Hamrun
Iklin
Isla
Kalkara
Kercem
Kirkop
Lija
Luqa
Mdina
Melliea
Mgarr
Marsaskala
Mqabba
Marsa
Msida
Mosta
Mtarfa
Munxar
Marsaxlokk
Nadur
Naxxar
Paola
Pembroke
Pieta
Qala
Qormi
Qrendi
Rabat
Safi
San Giljan
San Gwann
Siggiewi
San Lawrenz
Sliema
Santa Lucija
Sannat
San Pawl il-Bahar
Santa Venera
Swieqi
Tarxien
Ta Xbiex
Victoria
Valletta
Xewkija
Xgajra
Xagra
Zebbug
Zabbar
Zebbug
Zejtun
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Arno
Aur
Bokak
Bikini
Bikar
Ebon
Erikub
Enewetak
Jabat
Jemo
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Kili
Kwajalein
Lae
Lib
Likiep
Mili
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Mejit
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Toke
Ujae
Ujelang
Utirik
Wotho
Wotje
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Assaba
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Inchiri
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Tagant
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Tiris Zemmour
Agalega Islands
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Port Louis
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StO?a Nistrului
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Orhon
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Hentiy
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Tov
Selenge
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Ad Dakhla
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Federal Capital Territory
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Imo
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Niamey
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Oyo
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Zinder
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Buskerud
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Antananarivo province
Antsiranana province
Fianarantsoa province
Mahajanga province
Toliara province
Toamasina province
Balaka
Blantyre
Chikwawa
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Bamako Capital District
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Monagas
Nueva Esparta
Portuguesa
Sucre
Tachira
Trujillo
Yaracuy
Zulia
Federal Dependency
Vargas
Delta Amacuro
Amazonas
An Giang
Bac Ninh
Bac Giang
Binh Dinh
Bac Kan
Bac Lieu
Ben Tre
Binh Phuoc
Ba Ria-Vung Tau
Binh Thuan
Binh Duong
Cao Bang
Ca Mau
Can Tho
Dien Bien
Dak Nong
Dong Nai
Dak Lak
Da Nang
Dong Thap
Gia Lai
Hoa Binh
Ho Chin Minh
Hai Duong
Ha Giang
Ha Tinh
Ha Noi
Ha Nam
Hai Phong
Ha Tay
Hau Giang
Hung Yen
Alo
Sigave
Wallis
Abyan
Adan
Amran
Al Bayda
Ad Dali
Dhamar
Hadramawt
Hajjah
Al Hudaydah
Ibb
Al Jawf
Lahij
Marib
Al Mahrah
Al Mahwit
Sadah
Shabwah
Sana
Taizz
Copperbelt Province
Central Province
Eastern Province
Lusaka Province
Luapula Province
Northern Province
North-Western Province
Southern Province
Western Province
Bulawayo (city)
Harare (city)
Mashonaland Central
Midlands
Mashonaland East
Manicaland
Matabeleland North
Matabeleland South
Masvingo
Mashonaland West
State or Province
City
Zip or Country Code
Primary Diagnosis/Disease
Physician Name
(Required)
Physician Phone
Primary Disease Diagnosis
Primary Symptoms/Medical Conditions:
Date of Diagnosis
MM slash DD slash YYYY
Medical Records Available?
Yes
No
Current Medications
Anticoagulated?
Yes
No
Anticoagulated Since When
Anticoagulated?
Yes
No
Why Anticoagulated?
Subject History: Cancer
*Have you ever been diagnosed with any type of cancer?
Cancer Type
Date Cancer Diagnosed
MM slash DD slash YYYY
Cancer Status:
Subject History: Diabetes
Are You Diabetic?
Yes
No
Taking Insulin?
Yes
No
Subject History: Neurological System
Vision Decrease?
Yes
No
Vision Black Spots?
Yes
No
Vision Nistagmus?
Yes
No
Muscle Weakness?
Yes
No
Muscle Wasting?
Yes
No
Walking Difficulties?
Yes
No
Decreased Hand Strength?
Yes
No
Fainting?
Yes
No
Speech Problems?
Yes
No
Muscle Fasciculations?
Yes
No
Spasticity?
Yes
No
Hyperreflexia?
Yes
No
Hyporeflexia?
Yes
No
Depression?
Yes
No
Loss of Memory?
Yes
No
Headaches?
Yes
No
Sleep Disturbances?
Yes
No
Dizziness?
Yes
No
Subject History: Pulmonary System
Asthma?
Yes
No
Chronic Bronchitis?
Yes
No
Chronic Cough?
Yes
No
Emphysema?
Yes
No
Tuberculosis?
Yes
No
Subject History: Cardiovascular Problems
Myocardial Infarction?
Yes
No
Myocardial Infarction Date
MM slash DD slash YYYY
Angina Pectoris?
Yes
No
Tachycardia?
Yes
No
By-Pass Surgery?
Yes
No
By-Pass Surgery Date
MM slash DD slash YYYY
Hypertension (high blood pressure)
Yes
No
Hypotension (low blood pressure)?
Yes
No
Subject History: Circulatory
Poor Arterial Circulation?
Yes
No
Poor Venous Circulation?
Yes
No
Leg Cramps?
Yes
No
Tired Legs?
Yes
No
Swollen Ankles?
Yes
No
Varicose Veins?
Yes
No
Falling Asleep of the Hands and Legs?
Yes
No
Tingling Sensation in Arms and Legs?
Yes
No
*Ulcers or open wounds anywhere on your body?
Yes
No
Subject History: Gastrointestinal Problems
Acid Indigestion?
Yes
No
Bloating?
Yes
No
Stomach or Duodenal Ulcer?
Yes
No
Stomach or Duodenal Ulcer Date
MM slash DD slash YYYY
Loss of Appetite?
Yes
No
Rapid Weight Gain?
Yes
No
Have You Had Upper GI endoscopy?
Yes
No
Rapid Weight Loss?
Yes
No
Overweight Problem?
Yes
No
Have You Had Upper GI endoscopy?
Yes
No
Upper GI Date
MM slash DD slash YYYY
Upper GI Results
Hepatitis?
Yes
No
Hepatitis Type
Gall Bladder Problems?
Yes
No
Gall Stones?
Yes
No
Icterus?
Yes
No
Recurring Diarrhea?
Yes
No
Subject History: Upper Respiratory Test
*Chronic Sinusitis?
Yes
No
*Allergic Sinus Problem?
Yes
No
*Chronic Allergic Rhinitis?
Yes
No
*Chronic Nose Bleeds?
Yes
No
*Sinus Headaches?
Yes
No
*Chronic Colds?
Yes
No
Subject History: Rheumatic Screen
Soft Tissue Rheumatism?
Yes
No
Articular Rheumatism?
Yes
No
Joint Pain?
Yes
No
Back Pain?
Yes
No
Rheumatoid Arthritis?
Yes
No
Other Rheumatic Conditions
Subject History: Endocrinological System
Diabetes Mellitus?
Yes
No
Overactive Thyroid?
Yes
No
Underactive Thyroid?
Yes
No
Adrenal Gland Dysfunction?
Yes
No
Female Menopause?
Yes
No
Male Menopause?
Yes
No
Other Endocrinological Conditions:
Health History Allergy
*Food Allergy, Especially Eggs?
Yes
No
*Hay Fever?
Yes
No
*Allergic Asthma?
Yes
No
*Medication Allergies?
Yes
No
Medication Allergy Symptoms
Yes
No
*Allergies to any vaccinations?
Yes
No
*Do You Smoke Pipes?
Yes
No
Subject History: Other
When was your last vaccination?
*Do you drink wine?
Yes
No
*Do You Smoke Cigarettes?
Yes
No
*Do You Smoke Cigars?
Yes
No
How Much Do You Smoke Per Day?
*Do you drink beer?
Yes
No
*Do you drink hard liquor?
Yes
No
How much do you typically drink per day?
*Please list any nutritional supplements you are taking
*Other Significant or Chronic Illnesses
Do You Take Human Growth Hormone?
Yes
No
How Long Have You Taken Growth Hormone?
Human Growth Hormone Injections per Week
PSA Test (Men Only)?
Yes
No
PSA Test Date
MM slash DD slash YYYY
PSA Test Result
Periodic Mammograms (Women only)?
Yes
No
Mammogram Test Date
MM slash DD slash YYYY
Mammogram test results
MM slash DD slash YYYY
Surgical/Hospitalizations
Surgical Procedure 1
Surgical Procedure 1 Date
MM slash DD slash YYYY
Surgical Procedure 2
Surgical Procedure 2 Date
MM slash DD slash YYYY
Surgical Procedure 3
Surgical Procedure 3 Date
MM slash DD slash YYYY
Other Surgical Procedures
Family History
Has any member of your family had any of the following:
Hypoglycemia?
Yes
No
Diabetes?
Yes
No
Thyroid Problem?
Yes
No
Hormone Problem?
Yes
No
Cancer?
Yes
No
High Blood Pressure?
Yes
No
Kidney Problem?
Yes
No
Heart Problem?
Yes
No
Leukemia?
Yes
No
Arthritis?
Yes
No
Prostate Problem?
Yes
No
Mental Disorder?
Yes
No
Anxiety?
Yes
No
Lung Problem?
Yes
No
Fatigue?
Yes
No
Stroke?
Yes
No
Do you have any questions or comments?
By my signature below, I “Submit" 1) I attest that all information I have provided on this form is accurate and complete. 2) I understand that inaccurate or incomplete information may result in denial of treatment. 3) I confirm that I have read and understand the following information:
By completion and returning this application:
I attest that all information I have provided on this form is accurate and complete.
I understand that inaccurate or incomplete information may result in denial of treatment.
I confirm that I have read and understand the following information:
The science of treatment with adult stem cells is in its infancy.
The treatments described on LifeAlteringStemCells.com have not been evaluated by the US FDA and are not considered to be standard of care for any condition or disease.
There could be significant and unknown risks associated with adult stem cell treatments, as long-term studies have not been performed.
For most diseases, no prospective, randomized clinical trials of adult stem cells have been performed, therefore no guarantee of safety or effectiveness is made or implied.
Treatments by licensed doctors will only be performed after the patient understands and agrees to informed consent.
The results of testimonials of people who appear on this website who have undergone stem cell treatment are not necessarily typical.
If you are accepted for treatment by a doctor, the treatment will not be performed in the USA or Canada. It will be performed in Mazatlan, Mexico.
Please complete application and email back to: drmark@lifealteringstemcells.com
Applications may take up to 5 working days to review from the first working day they are received.
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Signature
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Date
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MM slash DD slash YYYY
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