Contact Us
Would you like to get in touch with us for medical advice on disease of any nature? Be it confidential or not, please feel free to consult our chief physician by filling in the form below. We will get back to you at the earliest.
Reference No :
(To be alloted by us. Please quote next time.)
Name :
Organisation :
Street Address :
City :
State :
Postal code :
Country :
Either the phone/fax number or the email-id is compulsory.
Telephone :
Fax :
E-mail :
Age :
Yrs
Sex :
Male
Female
Height :
Weight :
Kgs
Structure :
Obese
Lean
Medium
Nature of work: Whether it involves constant travelling, etc:
Present complaints with full history :
Has the patient or his/her near relatives had such complaint?
(Hereditary factor) if so, furnish details in brief :
Any cause known to you for the disease :
Any history of venereal disease, malaria, filaria or any other noticeable ailments:
State of Appetite, Digestion, Motion, Urine, Sleep:
Dietary habits :
Vegetarian or non vegetarian food articles being taken and their timings.
Addiction to smoking, alcohol, etc:
Marital status-married or unmarried.
Number of issues.
Menstruation, delivery, etc, problem if any:
Climate & present weather conditions of the place where he/she lives.
Any problem of pollution of air, water, etc.
Treatment done so far
Details of Investigation/Medical Reports
Any known Allergies :
Other information, if any:
Blood pressure:
