Online Medical Consultation

Thank you for your interest. Please provide the following information about your health problems. The information that you submit will not be used or distributed for any reason other than to fulfill your request. Please note that this form is only for exchanging of medical opinion so this institution does not take any responsibility for your health since medical examinations have not been performed face-to-face. This information will enable us to route your request to the appropriate doctor. You should receive a response within 48 hours. For security reason, IP address of your device on network will be recorded on successful submission.

Your General Information

Your Name*

Address

State

Pincode

Mobile Number*

E-Mail Address

Age*

Nationality*

Height in CM*

Weight in kg.

Sex* Male Female

Marital Status* Married Unmarried

Present Illness

Present Symptoms with duration (350 chars left)*

Treatment History

MRD Registration No if any

If already diagnosed, details (350 chars left)

Investigated details (if any)

Existing Health Issues

Diabetes Mellitus

High B.P.

Arthritis

Asthma

Allergy

Cancer

Family History of Disease

On any medication (350 chars left)

Any known Drug Allergy or Food Allergy (350 chars left)

Personal History

Sleep

Appetite

Addicted to Tobacco / Alcohol / Drugs

Present diet regime

Menstrual History if Female

Have you had any medical operation? Give details with Date (350 chars left)

Have you suffered from Cardiovascular problems? High BP Heart Attack Stroke

Enter Your Comments / Requirements (350 chars left)

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