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Patient Registration
Personal Information
Date of Birth:
Company That Will View The Results
Medical History
Kindly Click If you have any of the following sickness.
Diabetes
Heart Trouble
Blood Pressure
Shortness of Breath
Chest Pain
Chronic Cough
Asthma
Tuberculosis
Rheumatic Fever
Frequent Headaches
Vision Problems
20/20 Vision
Epilepsy/Seizure
Hearing Problems
Psychological Impairment/ Depression or Mental Illness
Sexually Transmitted Disease
Jaundice or Hepatitis
Dizziness
Back Problems
Slipped Disk
Wrist Problems
Fractured vertebrae
Arthritis/Gout
Kidney Problems
Cancer/Tumor
Rash or skin Problems
Hernia/Hydrocele
Varicose Veins
Drug Problems
Mental breakdown
Allergies
Gender Based Options
Value
Value
Value
Others
Please Leave Blank the Spaces if it doesn't apply to you.
Smoking any kind of Cigar
How long?
How Many Packs Per Day?
Drinking Alcoholic Beverage
How Often?
Do you use or take any Medical Drugs ?
How Often?
Are you presently under Medication(s)?
List all prescription medicines or over the counter medicines and how often.
Are you currently under a doctor’s care?
What problems?
List Physician’s Name and Address
Have you had surgeries and have been Hospitalized?
List dates and details:
Overall, would you say that your health is
Clinic Locations:
1405 The Jollibee center Building San Miguel Ave. Ortigas Center Pasig City,
Cluster 3 walkway extension, CENTRIS MALL, EDSA corner Quezon Ave. Quezon City
S01-S02 Second Floor SOUTHGATE Mall, Chino Roces ave. cor. EDSA, Makati City
Contact:
Telephone:+63 739-1991 Mobile:+63 917-517-1991 | +63 919-006-9437
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