Get Case Report Form Supplement Dementia Symptoms And ... - Celltex 2020-2025

Filling out the Case Report Form Supplement for dementia symptoms is an important step in contributing to ongoing research and understanding of stem cell therapy. This guide provides clear instructions on how to accurately complete each section of the form online.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to access the form and open it in your editing tool.
2. Start by entering your loved one’s full name in the designated field at the top of the form.
3. Indicate your loved one’s gender by selecting either 'Male' or 'Female' from the options provided.
4. Fill in your loved one’s date of birth using the format (MONTH/dd/yyyy). This is crucial for identification purposes.
5. Record the survey date, ensuring you use the same date format as above.
6. Provide the name of the person completing the survey in the appropriate section.
7. Enter the NPI number, phone number, and email address of the individual completing the form.
8. Select the type of dementia your loved one has by marking the appropriate box next to either 'Alzheimer’s Disease' or 'Other'.
9. Note the date your loved one was diagnosed with dementia; if the exact date is unknown, provide an approximate time when symptoms began.
10. Rate your loved one’s overall quality of life on a scale from 0 to 10, where 0 is 'Worst Possible' and 10 is 'Best Possible'.
11. For the next section, indicate how often your loved one has exhibited specific symptoms in the last four weeks, by marking one option for each symptom.
12. Provide a pain score reflecting how much pain your loved one has experienced in the past week on a scale from 0 (No Pain) to 10 (Worst Pain).
13. Answer questions regarding any changes in medication since the stem cell therapy and the timeline of when improvements were noticed, if applicable.
14. Respond to questions about whether improvements have been consistent or faded over time, and your thoughts on the need for repeat therapies.
15. Indicate if any new health problems have been diagnosed since the therapy took place.
16. Finally, express whether you would recommend Celltex to others looking to try stem cell therapy.
17. If applicable, report on how various symptoms have been affected by treatments in the last nine months, selecting the appropriate response for each symptom.
18. Review all entered information for accuracy, and then save changes, download, print, or share the completed form as needed.

Complete your documentation online today to support research into dementia therapies.