Thank you for your interest in our service.In order for our medical team to evaluate whether or not you are eligible for treatment and recommend a relevant medical program and treatment for you, please fill in the form below to the best of your ability or with the help of your physician. Name* First Last Date of Birth* CountryPlease select oneAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweEmail* Please confirm your Email address is correct.PhoneHeightUnitCMINCHESWeightUnitKGPOUNDHistory and DiagnosisWhat is your Primary diagnosis?* When were you first diagnosed? MM DD YYYY If you don't remember the specific date, just fill in the year of diagnoses with or without month.Please describe the progression of your condition from early symptoms until now. Have you taken surgeries or other therapies for your condition before? If yes, what’s the program? (Medication, dosage and period, etc.) Does anyone in your family have medical history relevant to your condition? SymptomsPlease list your main complaint currently and all your current general condition: (appetite/ performance of daily activities/ fatigue/ morning stiffness/ pain in joints, etc.) MedicationsPlease list any medications that you are currently taking with dosage and effectiveness and / or side effects What is the date of the last treatment and the effect? Please list the diagnostic exams you have had along with date, results and if images are available on request. Any medical records that you can send us will be helpful for your medical evaluation.Be sure to include with the forms the following information:* Medical reports from local doctor’s visits and disease history, with physical examination of Myodynamia (muscle strength) and Knee Joint Range of Motion* Examine by Imaging Result: X-rays Film Image and Magnetic resonance imaging (MRI). Whole blood test: * Hematocrit (HCT) and hemoglobin (Hgb) counts* White blood cell count (WBC) * Platelet count* Erythrocyte sedimentation rate (ESR) * Liver enzyme tests/Liver function test* The creatinine test measures kidney function and more Immunological Blood Tests * Rheumatoid factor (RF, Latex) * C-reactive protein* HLA B27* Urine Tests, Bone density test and Electrocardiogram (ECG)(Please note: MRI or X-ray scan must be within last 30 days) FileFileFileFileFileHypertensionNoYesHeart diseaseNoYesDiabetesNoYesCVA/ StrokeNoYesLung diseaseNoYesLiver diseaseNoYesKidney diseaseNoYesFracture or breakNoYesCancer or tumorNoYesInflammation or infectionNoYesOthersNoYesPlease explain, give exact diagnosis and date of diagnosis.Other informationIs there a caregiver who can provide you with care and assistance during your stay at the hospital if necessary?NoYesDo you smoke?NoYesAre you currently using or ever used drugs or alcohol?NoYesDo you have sleep apnea, chronic obstructive pulmonary disease or other condition that doesn't allow for general anesthesia?NoYesIf you answered yes to any of the above, please clarify. Validation This is to prevent spam.