ACTL Immunotherapy Research Application Form

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History of autoimmune disease: Yes No
Under treatment with immune inhibitor: Yes No
History of cardiovascular diseases or kidney failure: Yes No

Currently in period of disease： Yes No
History of allergy： Yes No
History of Surgery： Yes No
History of chemotherapy and/or radiotherapy： Yes No
Blood test results：
Liver Function： Yes No
Kidney Function： Yes No
Infectious Disease：
HBV： Yes No
HCV： Yes No
Syphilis： Yes No
HIV： Yes No
MHC Class I Molecule：
Positive Negative Unknown

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