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Consultation 2017-02-26T11:59:41+00:00

Please fill the online consultation form below. After careful analysis, our medical team will get back to you with personalized suggestions.

Name*
Nationality
Date of Birth
Height (cm)
Weight (Kg)
Sex
Occupation
E-mail address*
Telephone
Fax
Marital Status
Does your complaints aggravate during (please tick)
ExertionExerciseNormal activityAny otherRest
Past Medical History
Family Medical History
Road Traffic Accidents
Surgical History
Allergies to any medicine or food

Present complaint with duration (most serious problem first)
Symptoms with duration

1.
2.
3.
4.
If already diagnosed - details
Investigated details (if any)

Do you have any of the following

Disease
Select, if you have any
Duration
(in Days/Months/Years)
Current Medication
Diabetes Mellitus Diabetes Mellitus
Hypertension Hypertension
Heart disease Heart disease
Elevated Cholesterol Level Elevated Cholesterol Level
Bronchial Asthma Bronchial Asthma
Skin infection Skin infection
Thyroid Problem Thyroid Problem
Hair falling Hair falling
Diabetes Mellitus Diabetes Mellitus
Enlarged Prostate Enlarged Prostate
Cancer Cancer
Disk problems Disk problems
Arthritis Arthritis
Stroke Stroke
Sleep disorder Sleep disorder
Stress Stress
Mood change Mood change
Addiction to tobacco/alcohol Addiction to tobacco/alcohol
Osteopenia/Osteoporosis Osteopenia/Osteoporosis
Others Others


Investigation done - details if available
Diagnosis
Drugs prescribed with dose and how long taking them

Most recent tests done

X-ray Urine Analysis Stool Exam
Colonoscopy Lipid profile PSA
Blood Sugar H.crit Bun
Uric Acid Hb MRI
CT

Additional Details

Details of children

Male Age
Female Age

For Females (Menstrual Cycle)

Regular
Irregular
Menopause
Pap smear
Mammogram
Hot flush