Adult Registration Form

Dear Patient,

Please fill up these questionaire to assist the doctor in giving

a better understanding of your health problems.

This information will be treated as confidential.

Thank you.

Personel Data & History

Name of Patient:

Gender:

Male

Female

(IC/Passport No.)

Date

Date of birth:

Email Address:

Country

Nationality

Skype address:

Phone No.:

Blood group

Rhesus

+

-

A

B

AB

O

G6PD deficiency:

Yes

No

Height (cm):

Weight (kg):

BMI:

Age:

Mailing address:

Occupation:

Next of Kin:

Name

Phone No:

Relationship:

Current Medications:

Current Vitamins:

Paternal(father) history

Heart disease

Stroke

High blood pressure

Diabetes

Thyroid disease

Gout

Asthma

Arthritis

Depression

Anxiety

Addiction

Cancer

Autoimmune

Psychiatric Disorder

High Cholesterol

Genetic Abnormality

Autism

Maternal(mother) history

Heart disease

Stroke

High blood pressure

Diabetes

Thyroid disease

Gout

Asthma

Arthritis

Depression

Anxiety

Addiction

Cancer

Autoimmune

Psychiatric Disorder

High Cholesterol

Genetic Abnormality

Autism

Drug/Food sensitivities:

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