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Date of Birth
Marital Status SingleMarriedDivorcedWidowed
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How many Children you have?
Last Menstrual Period (Optional)
Are you Pregnant or Planning Pregnancy? YesNo
Are you breast feeding? YesNo
NoneDiabetesHypertensionElevated CholesterolAsthmaHeart DiseaseStrokeCancerHIV/AIDSDepressionSeizuresStomach UlcersGlaucomaSTDPsychiatric Disorder
NoneTonsillectomyAppendectomyGallbladder RemovalHysterectomyBowel SurgeryPlastic Surgery
NonePenicillinAmoxicillinTetracyclineAspirinIbuprofenNaproxenSulpha DrugsCarbamazepineLamotrigineErythromycinAzithromycinCodeinePseudoephedrine
Do you smoke? No0-1 pack/day1-2 packs/day2+ packs/day
Do you consume alcohol? NoDailyWeeklyMonthlySocially
Do you use or do you have history of using illegal drugs?* YesNo
Do you use Cannabis? YesNo
Have you travelled in last 1 month, if yes please list down your travel history? YesNo
COVID 19 AdvicePrescription RefillGeneral Health QuestionCough/Cold/Flu/FeverSore ThroatEar/Eye/ThroatUrinary InfectionSkin Problem (Acne/Rash/Eczema/Moles/Warts)Erectile Dysfunction (Viagra, Cialis, Levitra etc)Birth Control or Plan BOther
Please arrange free medication deliverySend it to my own pharmacy
The Physician has offered to communicate using the following means of electronic communication. Phone Email Website / Portal Videoconferencing (including doxy, zoom and other secure video platform)
I acknowledge and understand that encryption software be used as a security mechanism for electronic communications, it is still possible that communications with the Physician or the Physician’s staff using the Services may not be encrypted. Despite this, I agree to communicate with the Physician or the Physician’s staff using these Services with a full understanding of the risk. I acknowledge that either I or the Physician may, at any time, withdraw the option of communicating electronically through the Services upon providing written notice.
