Pre- Consultation Questionnaire

  • Name: Praveen Kumar
  • Gender: Male
  • Age: 32Yrs 3mn
  • Blood group: O+
  • Height: 5.8 ft-Inch
  • Weight: 72
  • Alcohol: No
  • Smoking: No
  • Lifestyle: Sedentary
  • Work Env: No Stress

Filled by Self

Drug Allergies : No

Envirnomental Allergies : No

Food Allergies : No

Other Allergies : Not Applicable

Are you currently taking any medications?

History of similar symptoms?

Number of days of present symptoms?

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Filled by nurse / reception / self

Blood Pressure

Systolic

Diastolic

Temperature

oF

Sp02(%)