Online Counsultation Name Nationality Age Height (cm) Weight (Kg) Sex —Please choose an option—MaleFemale Occupation E-mail address Telephone Marital Status MarriedUnmarriedDoes 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) Investigation done – details if available Diagnosis Drugs prescribed with dose and how long taking them Most recent tests doneX-rayUrine AnalysisStool ExamColonoscopyLipid profilePSABlood SugarH.critBunUric AcidHbMRICTAdditional Details Details of children Male Age Female Age For Females (Menstrual Cycle) Regular Irregular Menopause Pap smear Mammogram Hot flush Δ