Name

Address

Local Government

State

Age

Gender Male Female Other

Relationship Status Single Married Divorced Widowed

Phone Number

WhatsApp Number

Email

Patient Complaint

Have you had any symptoms before?

If yes, when?

Check the conditions that apply to you:

Blood Group

Genotype

Current Medications

Past Medical History

Are you pregnant? No Yes

Do you smoke? No Yes

Do you drink alcohol? No Yes

Do you use illegal drugs? No Yes

If yes, how often?

Are you sexually active? No Yes

If yes, how many sexual partners do you have?

Blood Pressure

Pulse Rate

Temperature

Respiration

Upload Medical Results