Consultation

Name

Age

Email

Date

Time

Skype

Presenting Complaints: (To be mentioned in the order of severity and the duration) *

History of present illness: (History of onset of each attack and the duration) *

Treatment History

Present Medications

Personal History

Appetite

Bowel

micturation

Sleep

Stress level

Mental status

Food

Allergic to
FoodSmellOilClimateMedicinesOther

Details of Allergy

Exercise

Nature of Job

Physical presentations

Height

Weight

Menstrual History

Sexual Habits

Family History

History of similar diseases in the family:

Latest Pathologic Examination Results: (Kindly mention the normal values if available) *

Diagnosis of the current medical Doctor *

Some more specifications to make us understand your body better *

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