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First Name

Middle Name

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Date of Birth

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Mobile Phone Number 1

Alternative Number

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Home Address

Medical Query

How can we help you? Select Service

Other

Describe Your Medical Issue or Symptoms

When Did The Problem Start?

How Did It Start?

Is this the first time? Yes or No

Yes No

What Makes It better or Worse?

Are you currently on Medication? Yes or No

Yes No

If Yes, list Medication

Have You Been Admitted in Hospital Before? Yes or No

Yes No

Do You Have High Blood / DM / (Sugar Disease) / Asthma / Cholesterol / Heart Problem or Any Other Condition? Yes or No

Yes No

If yes what is it?

When were you diagnosed?

Are you on treatment? Yes or No

Yes 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

Yes No

If Yes, What Is The Condition?

Is there any family member with any other Chronic Condition? Yes or No

Yes No

If yes, what is the Condition?

Are You Allergic to Any Medication? Yes or No

Yes No

If yes, what are you allergic to?

Are Your Parents Alive and Well? Yes or No

Yes No

If Alive But Not Well Can You State Their Condition?

If Not Alive WHat Happened To Them?

Social Enquiry

Are you working? Yes or No

Yes No

If yes, what type of work?

Do you drink? Yes or No

Yes No

If yes, what do you drink?

How much do you drink?

If no, did you ever drink?

Yes No

If yes, how long ago did you stop drinking?

Any reason for stopping?

Do you smoke? Yes or No

Yes No

If yes, what do you smoke?

How much do you smoke?

If no, did you ever smoke? Yes or No

Yes No

If yes, how much did you smoke?

How long ago did you stop?

Any reason for quitting?

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