[Regenerative Medicine & Stem Cell Therapy] Aoyama Medical Clinic – For Regenerative Medicine & Stem Cell Therapy in Tokyo

1. Could you tell us the background for your request today?

Treatment of illness

Anti-aging

Cosmetic dermatology

Cosmetic surgery

Slimming

Others

2. What kind of symptoms are you experiencing?

3. Are there any treatments or examinations you are interested in from the list below?

Exosome・stem cell therapy

Next generation PRP therapy

NMN・NAD・Cell-Actin

Cancer screening・treatment

DNA telomere test

Vascular age test

Hormonal age test

Gut flora test

Allergy test

Immune activity test

Cosmetic dermatology treatment

Cosmetic surgery treatment

Beauty IV Drip

Others

4. Have you ever had any major illnesses or surgeries?

No

5. Are you currently receiving treatment for any illness?

No

6. Are you currently taking any medications?

No

7. Do you have any allergies?

No

8. Do you smoke cigarettes?

No

9. Do you drink alcohol?

No

10. (For women) Are you pregnant, breastfeeding, or is there a possibility of pregnancy?

No

11. Have you ever had a blood transfusion?

No

12. Have you ever received treatment at a cosmetic clinic before?

No

13. Please let us know which parts of your body you are concerned about.

14. What is your budget for the treatment?

USD

15. Is there anything else you are worried about or would like to share with the doctor?

No

16. How did you hear about our clinic?

17. May we send you emails about campaigns and other information?

Yes

No

Medical questionnaire