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Patient Name
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First Name
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Email
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Age
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Gender
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Address
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Health Check
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Heart Rate
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Height (in feet and inches)
Weight (in kilograms)
Blood sugar (in gm/dl)
Please explain why do you want a consultation?
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History of past illness (if any)
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Family History (Does any of your blood relation suffer from similar illness?)
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Drug History (Do you use any drug, alcohol or tobacco habitually)
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Do you have any experience of using cannabis in any form ? if yes please explain in which form and side effects if any
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Rate your sleep on scale 1 to 5
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Best
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1 is Worst, 5 is Best
Are you allergic to any drug, antibiotic or any other supplement?
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Current Medication, If any
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