Consultation Form
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Name *
Age (in yrs.) *
Gender *
Height (in cm) *
Weight (in Kg) *
Type of Consult *
Contact Number *
Medical complaints / symptoms with brief description, for which consultation is being taken *
What is the duration of above medical complaints? *
Have you ever been treated in the past for the same complaints? *
Mark Yes, if you have any of the following medical conditions? *
Yes
No
High Blood Pressure
Heart Disease
Diabetes
Asthma
Chronic Bronchitis
Present or past Tuberculosis
Kidney Problem
Undergone any surgery or procedure
Undergone treatment for any Cancer
Any other significant illness
If answer to any of the above is Yes - How long ago were you diagnosed or treated for the medical condition(s)?
List the medicines (with dosages) that you are currently taking?
Mark Yes, if anyone in your family (father/mother or siblings) suffer/suffered from following medical conditions? *
Yes
No
Diabetes
High Blood pressure
Heart Disease
Cancer
Any other significant illness
Mark Yes, if you do any of the following? *
Yes
No
Smoke
Chew Tobacco
Consume alcohol more than twice a week
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