Medical questionnaire

Personal data

Please check the appropriate boxes

Liver and pancreatic diseases

Hepatitis

Diabetes

Diabetes
Insuline

Cancer

Yes

SurgeryRadiotherapyChemotherapy

Thyroid disease ?

Yes

Cardiac disorders

Heart attack

StentChest anginaArterial hypertension

Infections

HIVTuberculosis

Allergies

Yes

Articular rheumatism

Yes

Respiratory disorders

AsthmaEmphysema

Your habits

Smoke
Alcool

Other illnesses

Do you take medications ?

Yes

Have you already had a cell therapy ?

Yes

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