Medical Questionnaire - Tokyo: The Japan Regenerative Medicine Center for Diabetes and more - 糖尿病等の再生医療治療なら一般社団法人日本再生医療センター（東京）

Tokyo: The Japan Regenerative Medicine Center for Diabetes and more

Japan Regenerative Medicine Center

Level 11, Aoyama Palacio Tower, 3-6-7 Kita-Aoyama, Minato-ku, Tokyo,107-0061 Japan

Business hours are as follows	10:00am - 5:00pm

Closed on	Saturdays, Sundays and public holidays

Please feel free to contact us

+81-3-5464-8686

CONTACT FORM

MENU

MEDICAL QUESTIONNAIRE

Please fill in the form below and submit to us by clicking “send” bottom.

Absolutely no fees will arise at the time of your application.

Whether you have a query or need some information, our team is available to help via phone or
contact form. Please feel free to contact us.

Regenerative Medicine Treatment Application
Form and Questionnaire

※ Orange colour (必須) indicates mandatory field. Please fill in or select all mandatory fields.

Name 必須	（ex. John Smith）
Gender 必須	Male Female DK, NA
Blood Type 任意	A B O AB
Date of Birth 必須	（ex. 06/14/1952）
Address 必須	（ex. 1234 West New Haven, Apartment #23, Jamestown, WV, 55555, USA）
Occupation 必須	（ex. Office worker, None, etc.）
Phone 必須	Home Mobile
Phone Number 必須	（ex. ＋1-310-123-4567）
Preferred Contact Information 必須	Same as above None of the above (Please specify)
任意	（ex. ＋1-212-123-4567）
E-mail 任意	（ex. sample@john.com）
Please select one of the documents on the right (You　can mark multiple options) 必須	Physical examination records Blood test results Medical certificate　　　 Other (Please specify)
任意
Are you　currently undergoing regular treatment with any of the following　medical professio-nals? 必須	No Yes (Please select below)
(You can mark　　multiple options) 任意	Physician Surgeon Orthopedic surgeon　 Dermatologist　　　　 Urologist　　　　　　 Otolaryngologist (Ear or nose or throat)　　　　　　 Ophthalmologist Dentist　　　　　　　　　　 Obstetrician/Gynecologist Other (Please specify)
任意
Are you　currently undergoing treat-ment for any of th-e following ? 必須	No Yes (Please select below)
(You can mark　　multiple options) 任意	Heart illness (myocardial infarction, angina pectoris) Cerebral infarction, Cerebral hemorrhaging　　　　　 High blood pressure Diabetes　　　　　　　　 Respiratory disorder Hepatitis B/C Epilepsy Arrhythmia HIV Atopic dermatitis　　　　　 Kidney illness Cancer　　　　　　　　　　　　 Other (Please be as specific as possible)
任意
Are you　currently taking any medic-ation or suppleme-nts? 必須	No Yes (Please be as specific as possible)
任意
Have you ever had any of the followi-ng health issues in the past? 必須	No Yes (Please select below)
(You can mark　　multiple options) 任意	Asthma Pneumonia Cancer　　　　　　 Stomach/duodenal ulcer Gallstone Gout Heart illness Arrhythmia Kidney illness　　 Other (Please be as specific as possible)
任意
Have you ever had an allergic reactio-n to medication or food? 必須	No Yes (Please list all allergies to prescription and over-counter medicines, foods, and the allergic reaction.)
任意
Have you ever un-dergone surgery or received a blood　transfusion in the past? 必須	No Yes (Please be as specific as possible)
任意
Have you ever ex-perienced any of　the following after receiving an IV?　(You can mark　　multiple options) 必須	Adhesive irritation Rash from rubbing alcohol　　 Vascular pain/Inflammation Nausea　　　　　 Prolonged bleeding　　　　　　　　　　　　　　　 Other (Please be as specific as possible) N/A
任意
Do you smoke? 必須	No Yes (Please be as specific as possible)
任意	（ex. Around ten cigarettes a day for 20 years）
Do you drink alco-hol? 必須	No Yes (Please be as specific as possible)
任意	（ex. a can of beer four times a week）
Do you exercise? 必須	No Yes (Please be as specific as possible)
任意	（ex. jogging everyday）
Height（cm）必須	（例：185）
Weight（kg）必須	（例：81）
This question is　 for women only. 　Is there any possi-billity that you mi-ght currently be　pregnant? 任意	Not pregnant May be pregnant　　　　　　　　 During pregnancy (How many weeks? Please fill in below)
任意	（ex. 18 weeks）
Other: Please use the following spa-ce to note any ad-ditional items bef-ore receiving trea-tment. 任意

Results of examinations at our Medical Center may be used for purposes including, but not limited to, creating research documents for presentations at academic conferences. In these cases, we will use
the results to work towards the development of regenerative medicine in Japan bearing in mind
privacy and taking care that no individuals can be identified.

　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　 Thank you for your cooperation.

CONTACT US

Please feel free to contact us

+81-3-5464-8686

Business hours are as follows 10:00am - 5:00pm (Closed on
Saturdays, Sundays and public holidays)
※ There will be the automated voicemail guidance, please
leave a message after the tone. We will get back to you in a
timely manner.

※ The contact form is available 24/7.

Here is the Contact form

Call us for inquiries

+81-3-5464-8686

Business hours are as follows
10:00am - 5:00pm (Closed on Saturdays, Sundays and public holidays)
※There will be the automated voicemail guidance, please leave a
message after the tone. We will get back to you in a timely manner.

You can reach us via the Contact
form below for 24/7. Please do not
hesitate to contact us.

Here is the Contact form

Click here for Contact

Regenerative Medicine Treatment Application Form and Questionnaire

CONTACT US

Regenerative Medicine Treatment Application
Form and Questionnaire