Please fill out the application below and submit to us online or
click here to download the PDF version of the application to print and FAX to us.
Tel: (+66)(2)619 5307 Fax: (+66)(2)619 6122
 
Download Patient Form

Baseline Paticipant Report
Section A
To be compelete by the Paticipant

Personal Paticipant Details  
Name
D.O.B
Marital status
Occupation
Contact telephone number
E-mail address
Name and contact details of Reporting physician
List any allergies
Date and place of treatment
Personal-companion accompanying
You to the treatment clinic
Contact number of companion
   
 Condition Related Details  
   
Medical condition
Date of diagnosis
Present symptoms
Ambulation aids used
Current list of medication taken Within the last month
   
Please list other medical illnesses, allergies and operations
 
Signed at (place)                  on (date) 2007

Participant’s signature
Participant’s name in print
Participant’s ID or Passport number

Section B

Phycisian's details

Name
Qualifications
Medical license number
Are you contracted with IBS? Yes NO

Clinical Notes

Frontline observations

Weight
Pulse
Blood pressure
Temperature
Respiratory rate
Visual acuity (Snellen Chart)

Urinary dipstix analysis

  • Glycosuria
  • Ketonuria
  • Leucocytes
  • Nitrites
  • Haematuria
  • Urobilinogen

Frontline objective report by medical examiner

What is your assessment of the participant’s mood?
What specific queries/worries does the participant express?
How were these issues addressed?
In your opinion, does the participant
understan what the treatment entails?
Has the informed consent been signed? Yes No
Participant’s History overview
Hay you reviewed the participant’s original application form,
the participant’s condition, medications and medical records?		 Yes No
Participant’s physical and general examination

Review frontline observations and list any abnormal results

Does the participant use any ambulatory aids?

 Yes No
Is there catheter/stoma present? Yes No
Pallor/Juandice/cyanosis/oedema/lymphadenopathy? Yes No
What is the participant’s nutritional status?
Are there any skeletal deformities?
(inspect the limbs and spine)
Does the participant have any bed sores? Yes No
If yes, please delineate anatomical position, size and dressing
Is there any evidence of a rash or existing skin conditions? Yes No

System review
(list all abnormal findings; if system “normal” indicate with NAD concentrated examination of the specific system(s) affected by the participant’s condition)
Cardiovascular :
Respiratory:
GIT:
Musculoskeletal (please list any skeletal
deformities or grade the neuromuscular conditions (1-5) on all major muscle groups:

Neurological
  • Higher functioning
  • Neck stiffness/Kernig sign
  • Abnormal movements
  • Cranial nerves (gross exam)
  • Gait
  • Romberg sign
  • Muscle wasting
  • Muscle tone
  • Reflexes
  • Sensation (soft touch, pain, proprioception and vibration
    sense in all major dermatomes:
  • Co-ordination (gait, past pointing, heel-shin,
    dysdiadiokinesis, etc.):

 

Special investigations taken at clinic
  • Blood tests

 

Stem cell therapy administration
Vial ID
Batch No
Date on vial
Description on vial
Site(s) of injection

 

Post neonatal stem cell therapy observation (1 hour)
Document ? hourly observations
1st quarter obs BP: Pulse: Temp:
Allergies/AEs:
2nd quarter obs BP: Pulse: Temp:
Allergies/AEs:
3rd quarter obs BP: Pulse: Temp:
Allergies/AEs:
4th quarter obs BP: Pulse: Temp:
Allergies/AEs:
Document any comments made by the participant regarding their condition,
the stem cell therapy prior, during and after administration

DO NOT FORGET DOCUMENT THE VIAL NUMBER AND
CHECK THE PARTICIPANTS NAME AGAINST IT

Signed at (place) on (date) 2007

Treating physician’s signature
Treating physician’s name in print
Treating physician’s registration body
Treating physician’s medical license number

IBS Participant Release Form
Clinical Notes

Twenty four (24) hour follow-up observations
Weight
Pulse
Blood pressure
Temperature
Respiratory rate
Visual acuity (Snellen Chart)
Document any comments made by the participant regarding their
condition, the effects of the stem
cell therapy since they last visited the Treatment clinic (24 hours earlier)
Urinary dipstix analysis
  • Glycosuria
  • Ketonuria
  • Leucocytes
  • Nitrites
  • Haematuria
  • Urobilinogen

 

Special investigations taken at clinic
  • Blood tests
    		•
    Document any/all negative side effects or adverse effects the participant has experienced since their stem cell therapy
    Document any/all positive events that have occurred since the participant has had their stem cell therapy (in detail, if necessary refer to the applicants original rating scales for comparison purposes)
    I, Dr. (name)   hereby confirm that
    (Participant’s name) can be Released form the treatment clinic.  
    Signed at (place)                  on (date) 2007

    Treating physician’s signature
    Treating physician’s name in print
    Treating physician’s registration body
    Treating physician’s medical license number
    Signed at (place)                  on (date) 2007

    Participant’s signature
    Participant’s name in print
    Participant’s ID or Passport number
       
       

     
    		 
     
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