Medical Information and Evaluation Form

First name

Last name

Fecha de nacimiento

Month

Day

Year

Peso

Dirección

Telephone

Current illnesses or diagnoses

Relevant medical history

Current medications

Dietary supplements, vitamins, or other complementary therapies

Main reason for consultation or aspects you wish to improve

General level of energy, sleep, and appetite

Skin condition, circulation, and muscle tone (if you have noticed recent changes)

Stress level or emotional state (optional)

Have you previously received any cellular or regenerative therapy?

Recent test or diagnostic results (optional)

Any other information you consider important for your evaluation

Consent for Treatment and Use of Data: I declare that the information provided is accurate and authorize Biopharmacy México to use my data for medical analysis and guidance in regenerative therapies, with confidentiality in accordance with the law. (Signature)

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Medical Information and Evaluation Form

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