Ask A Doctor
Ask A Doctor
Ask A Doctor (Book Consultation)
Dr C.C. Clark
Date of Birth
State of Origin
Mobile Phone Number 1
How can we help you? Select Service
Chronic Disease Conditions
Describe Your Medical Issue or Symptoms
When Did The Problem Start?
How Did It Start?
Is this the first time? Yes or No
What Makes It better or Worse?
Are you currently on Medication? Yes or No
If Yes, list Medication
Have You Been Admitted in Hospital Before? Yes or No
Do You Have High Blood / DM / (Sugar Disease) / Asthma / Cholesterol / Heart Problem or Any Other Condition? Yes or No
If yes what is it?
When were you diagnosed?
Are you on treatment? Yes or No
If yes, what treatment are you on?
If no, why are you not on treatment?
Are You Taking Medication for Any Chronic Condition? Yes or No
If Yes, What Is The Condition?
Is there any family member with any other Chronic Condition? Yes or No
If yes, what is the Condition?
Are You Allergic to Any Medication? Yes or No
If yes, what are you allergic to?
Are Your Parents Alive and Well? Yes or No
If Alive But Not Well Can You State Their Condition?
If Not Alive WHat Happened To Them?
Are you working? Yes or No
If yes, what type of work?
Do you drink? Yes or No
If yes, what do you drink?
How much do you drink?
If no, did you ever drink?
If yes, how long ago did you stop drinking?
Any reason for stopping?
Do you smoke? Yes or No
If yes, what do you smoke?
How much do you smoke?
If no, did you ever smoke? Yes or No
If yes, how much did you smoke?
How long ago did you stop?
Any reason for quitting?
Preferred Date to Call
Preferred Time to Call
Preferred Mode of Contact
Upload Any Supporting Documents
Trinity Family Practice
Get In Touch
DSC, Warri, Nigeria
+234 (0) 8122513196
© Trinity Family Practice 2019 - All rights reserved