Autologous Fat-Derived Stem Cell Transplant
Plasitc Surgery
Minimal Invasive Procedure


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LCMI Website / Internet
Newspaper / Magazine
Flyer / Brochure
Friends / Relatives
Others (Specify)


MEDICAL / SURGICAL HISTORY

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Yes No

Fever
Weakness
Nausea
Blurring of vision
Colds
Mouth Sores
Difficulty hearing
Cough
Difficulty breathing
Difficulty walking


Difficulty swallowing
Chest pain
Palpitations
Stomach pain
Hyperacidity
Difficulty urinating
Difficulty defecating
Fractures, Sprains, Strains
Muscle Fatigue

Aspirin
Blood Thinner
Antibiotics
Analgesics
Anti-hypertensives
Antidepressants
Cough Medication
Others (Specify)







 
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