Patient Information Sheet

Download the Patient Info Sheet here

As part of your appointment process, kindly fill-up with your details completely the Patient Information Sheet. You may choose to (1) Download or (2) Fill-up the form below. Remember to answer every detail as much as possible, so our doctors can identify your health condition.

For any concerns or questions, kindly contact our Customer Relations Officer at 0908 811 4378. We value your compliance and will keep your records confidential. Thank you!

Name *
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Date of Birth *
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Age *
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Marital Status *
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Blood Type
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Nationality
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Religion
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Contact Number *
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Address *
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Email Address *
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Occupation
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Emergency Contact Person *
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Relationship to Patient *
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Contact number *
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Exposure to Occupational Hazards
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PLEASE CHECK THE APPROPRIATE BOX: *
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If allergic, which one:
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Smoking: *
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Sticks per day:
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Number of years:
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Alcohol: *
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How often:
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Street drugs/ Narcotics: *
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Dental fillings: *
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Number of years:
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Pregnant / Lactating: *
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TREATMENT INFORMATION *
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PATIENT HISTORY (Family History:) *
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Others:
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List all past and present serious illnesses and other medical conditions *
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CHIEF COMPLAINT: *
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DIAGNOSIS: *
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MEDICATION/S AND TREATMENT/S DONE: *
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PAIN ASSESSMENT Do you have pain now? *
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How do you rate your tolerance to pain? *
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Where is your pain located?
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Describe your pain:
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On a scale of 0 to 10 with 0 being no pain and 10 being the highest rate your pain now
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REVIEW OF SYSTEMS - GENERAL *
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REVIEW OF SYSTEMS - BREASTS *
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REVIEW OF SYSTEMS - EARS *
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REVIEW OF SYSTEMS - EYES *
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REVIEW OF SYSTEMS - NOSE/SINUS *
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REVIEW OF SYSTEMS - THROAT *
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REVIEW OF SYSTEMS - ENDOCRINE *
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REVIEW OF SYSTEMS - LUNGS *
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REVIEW OF SYSTEMS - HEART *
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REVIEW OF SYSTEMS - VASCULAR *
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REVIEW OF SYSTEMS - GI *
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REVIEW OF SYSTEMS - SKIN *
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REVIEW OF SYSTEMS - URINARY *
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REVIEW OF SYSTEMS - BONES/JOINTS *
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REVIEW OF SYSTEMS - NERVOUS SYSTEM *
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