DR. CARL NGAN APPOINTMENT

60MINUTE LIFESTYLE CONSULTATION FEE: ₱2,000

Here’s what’s you’ll consultation will look like:

• Simple personalized meal planning based on your lifestyle and goals
• Tailored exercise and physical activity guidance
• Sustainable lifestyle-centered health coaching
• Education to help you better understand and manage your condition
• Guidance for hypertension, diabetes, gout, and high cholesterol
• Supplement and nutrition support to improve adherence and results

PAY THRU (GCASH OR BPI)

GCASH:

Carl Schedrich Ngan

09274807002

BPI:

Acct Name: Carl Schedrich Ngan

Acct No. 9696 1336 31
DR. CARL NGAN APPOINTMENT

Schedule your appointment and fill up the necessary details:
GCASH / BPI PROOF OF PAYMENT SCREENSHOT

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Choose your appointment date and time
Choose your appointment date and time:
Full Name:

First NameLast Name
Email Address:
example@example.com
Facebook/ IG Profile
Active WhatsApp/Viber Number
Mobile Number:

Area CodePhone Number
Where are you currently residing:
For your convenience during the consultation, answer the questions about your health to the best of your ability.
Age:
GENDER:
MARITAL STATUS:

Other
Height:
Weight:
Occupation:
What brings you to seek consultation:

Other
Past Medical History (Check all that applies):
Other medical conditions that you have that are not on the list:
Family History (Check all that applies):
Other medical conditions in your family that you have that are not on the list:
List all your current Medications/ supplements/ oral contraceptives ( if applicable):
Allergies:
On the average how many servings of vegetables do you eat daily: ( 1 serving = 1 cup fresh vegetables of 1/2 cup cooked vegetables)

Other
On the average how many fruits do you eat in a day:

Other
How many meals do you eat per day:

Other
How often do you consume processed food/ fast food:

Other
What do you usually eat for BREAKFAST: ( include if you also drink coffee/ tea/ and if with sugar or creamer), include amount of food ( ex: 1 cup rice, 1 cup chicken, 1 cup veggies)
What do you usually eat for LUNCH: ( include amounts ex: 1 cup veggies, 1 cup chicken, 1 cup rice)
What do you usually eat for DINNER: ( include amounts ex: 1 cup veggies, 1 cup chicken 1 cup rice)
How often do you drink colored drinks: ( iced tea, fruit juices, etc)

Other
How often do you engage in physical activity/ exercise:

Other
What type of exercise do you do: (walking, gym sports, swimming, yoga, pilates, running, etc.)
What is the duration of your preferred exercise routine:

Other
How long is your average hours of sleep per night:
How would you describe your sleep quality:
Do you wake up freeling refreshed:
How would you rate your stress level:
How do you cope with stress:
Are you currently smoking:
Do you drink alcohol:
Do you use recreational drugs: (Marijuana, LSD, etc.)
For female patients, is your period regular:
For female patients, are you currently pregnant/ breastfeeding:
Over the past two weeks, how often have you been bothered by feeling down, depressed or hopeless:
Do you have trouble concentrating or sleeping:
Do you have any of the following symptoms, please check all that applies
What are your top 1-2 health goals right now:
Should be Empty:

DR. CARL NGAN APPOINTMENT

For your convenience during the consultation, answer the questions about your health to the best of your ability.