• SIM NATURALS LIMITED – General Medical History & Clinical Assessment

    Share your medical history and current concerns for clinical review—please upload only relevant documents and include country code for your phone number.

  • Patient and Contact Details

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex / Gender*
  • Format: (000) 000-0000.
  • Preferred Contact Method*
  • Format: (000) 000-0000.

  • Consultation Details

  •

  • Medical History

  • Surgeries / procedures

  • Reproductive History (Optional, Only If Relevant)

  • Are you currently pregnant?
  • Are you currently breastfeeding?

  • Lifestyle and Nutrition

  • Relevant Systems Review

  • Constitutional symptoms present?*
  • Constitutional symptoms
  • Cardiovascular symptoms present?*
  • Cardiovascular symptoms
  • Respiratory symptoms present?*
  • Respiratory symptoms
  • Digestive symptoms present?*
  • Digestive symptoms
  • Urinary symptoms present?*
  • Urinary symptoms
  • Musculoskeletal symptoms present?*
  • Musculoskeletal symptoms
  • Neurological symptoms present?*
  • Neurological symptoms
  • Skin symptoms present?*
  • Skin symptoms
  • Endocrine symptoms present?*
  • Endocrine symptoms
  • Mental and emotional health symptoms present?*
  • Mental and emotional health symptoms

  • Investigations and Records

  • Upload Instruction
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • Patient Goals and Context

  • Safety, Consent, and Declaration

  • Urgent symptom disclaimer
  • Privacy and confidentiality notice
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: