Follow-up – Type 1 Diabetes – Child – Throne Biotechnologies

Follow-Up Form

Type 1 Diabetes - Child

Follow-up Form - Type 1 Diabetes - Children

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Street Address

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Parent/Guardian City

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Parent/Guardian State

Parent/Guardian Zipcode

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Parent/Guardian Country

Parent/Guardian Phone

Parent/Guardian Email Address

Child's First Name

Child's Last Name

Child's Street Address

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Child's City

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Child's State

Child's Zipcode

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Child's Country

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Today's Date

Child's Birth Date

Child's Age In Years

Child's Sex

Female

Male

Patient Folder Name

Patient File Name

Child's Height in Feet

And Inches

Child's Weight (in pounds)

Child's BMI

What was the date of the child's first stem cell educator treatment?

If there was a follow-up stem cell treatment, what was the date of the last stem cell treatment?

Months since first stem cell treatment

Months since last stem cell treatment

How Many Units Of Long-Acting Insulin Does The Child Require Per Day?

How Many Units Of Short-Acting Insulin Does The Child Require Per Day?

List All Other Chronic Illnesses Or Disorders (enter "None" If none)

If The Child Has Recent Blood Test Results, Please Enter Them Below

Hemoglobin A1C Result

Date of result

Fasting Blood Sugar (Glucose) Result

Date of result

C-Peptide Result

Date of result

GAD Antibody Result

Date of result

IA2 Antibody Result

Date of result

ICA Antibody Result

Date of result

IAA Antibody Result

Date of result

Enter The Name, Address, Phone Number, And Email Address Of The Doctor And/Or Clinic That Provides The Child's Diabetes Care

List All Medications That The Child Takes For Any Reason Other Than Diabetes

List All Allergies To Any Drugs Or Anything Else. Enter "None" If None.

Required HIPPA Privacy Practices Notice: (Follow link below)

Yes, I have reviewed the HIPPA Privacy Practices Notice

HIPPA Privacy Practice Notice

Email Communication Authorization:

Yes, I give permission for Throne Biotechnology and Its doctors to communicate with me regarding my care by Telephone, Text Message, or Email.

If you are human, leave this field blank.

Follow-Up Form Type 1 Diabetes - Child

If The Child Has Recent Blood Test Results, Please Enter Them Below

Follow-Up Form

Type 1 Diabetes - Child