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Online Consultation Form

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Name *

First

Last

Email *

Gender *

• Female
• Male
• Other

Age *

Height (cm)

cm

Weight (kg)

kg

City *

Phone Numbers *

Email *

Occupation

Information about your illness

What is your diagnoses from a doctor?

What medical test have been conducted?

Is there any other information that might be helpful?

Medical History

Physical Generals – Preferred Weather?

Appetite

Thirst

Favorite Foods

Stool

Urine

Perspiration

Sleep Position/Pattern

Speed (Walking, Eating and Working)

Sensitivity (Noise, Light, Traveling, Perfume, Dust etc.)

Females: Gynae and Obs history

Females: Menstrual history

Females: Age of menopause

Females: History of abortions or miscarriage

Family history: Name the diseases which your father/ mother/ siblings might have suffered

Anything else you would like to share with the doctor?

Cigarettes per day

Alcohol drinks per week

week or medical

Exercise per week

Online Consultation Fee *

Price: $75.00

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