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* 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. Please explain your history of treatment and the results of those treatments (including different medications and alternative treatments): Does anyone in your family have medical history relevant to your condition? SymptomsPlease list all of your current symptoms: (mobility, performance of daily activities, speech, breathing, eating, metabolism, mental and emotional condition, etc.) Please list any actions or chores that you are unable to carry out: MedicationsPlease list any medications that you are currently taking with dosage and effectiveness and / or side effects Results of medical examinations (MRI, CT, X-Ray, EMG, ECG, EEG, etc.)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.If possible, please attach to the form below any or all of the following: MRI / CT images (on CD, Film, or via email) Medical records or recent neurological evaluation from your neurologist Video: a short video (3-5 minutes) showing the patient performing simple daily activities. You may use a simple home camera to prepare this video and send us via email or on a CD.FileFileFileFileFileHypertensionNoYesHeart diseaseNoYesPneumoniaNoYesDiabetesNoYesHyperlipidemiaNoYesCVA/ StrokeNoYesLung diseaseNoYesLiver diseaseNoYesKidney diseaseNoYesFracture or breakNoYesCutaneous basal cell carcinoma or in situ carcinomaNoYesCancer 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 have any infection, wounds or other problems with your lumbar area?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?NoYesAre you suffering from severe depression or cognitive impairment?NoYesDo you have active seizure disorder or are you taking anti-epileptic medications as seizure prophylaxis?NoYesAre you having a current treatment with anti-coagulants (blood thinners) or apomorphine?NoYesHave you ever had any treatments with immunosuppressive medications (such as systemic steroids)?NoYesHave you ever had any treatments before with phenol, botulinum toxin, baclofen, or any other interventional therapies for spasticity or dystonia?NoYesDo you have other diseases, previous therapies or any information that you think may be relevant for the evaluation?NoYesIf you answered yes to any of the above, please clarify. 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