Consultation Form

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Consultation Form

Online Consultation Form

Email*

Contact Number*

First Name *

Middle Name

Last Name*

Maiden Name

Address*

City/Town*

State*

Zip Code*

Country*

Nationality*

Date Of Birth*

Age*

Height(cm)*

Weight(kg)*

Gender*

Marital Status*

Profession*

Nature of Work and travelling

How frequently do you need to travel

How does your tongue look?*

Other Tongue color

Present Complaints – List of Present Complaints *

Duration of each present complaint*

Details Of investigation so Far

Family History of any illness?

Please upload files of investigations if any

Current Medication with Dose, if any

Allergies if any

History of Previous illnesses, if any (Past Medical History)*

If yes, specify duration, otherwise type NO

Admitted to hospital Before? If yes, for what reason?

Please mark if you have any of the diseases down below*

Other Disease

Bowel Habits*

Bowel Color

Urine Quantity*

Urine Color*

Other Urine Color

Appetite according to you

Diet

Other Diet

Breakfast menu and time

Lunch menu and time

Dinner menu and time

Any Snacks you eat apart from the above meals

Habits If any

Other Habit

Section For Covid-19

Have you been infected with Covid-19 before?

If yes, what were the symptoms you had?

Were you hospitalized due to Covid-19?

Are you suffering from any post Covid-19 complications?

If yes, please elaborate

Section For Women Only

Which of the Following describes your Menstruation?

How many days does your menstruation last?

Associated Symptoms Before or During Menstruation

Any Vaginal Discharge?

If there is a vaginal discharge, please describe any other observations with it

Are You Pregnant Now?

Do you use any Birth Control measures?

If yes, please describe

Number of Previous Pregnancies if any

Describe Previous Pregnancies if any – How was the delivery done? Any abnormality? any other History

Please add more information if you would like to add about your Disease/Problems

Please attach your recent photo