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Home E-Consultancy General Form
E-Consultation for General Patient
If you have a general complaint regarding any part of the body, Please Submit this form..

Name of the Patient
Age
Gender
Weight
Height
Profession
Marital Status
Email Address
Complete Postal Address
City
State/Province
Zip/Postal Code
Country
How is you appetite?
Do you have constipation?
Do you feel any burning sensation in chest/abdomen?
Type of food that you eat
Do you consume tobacco in any form?
Are you addicted to any other intoxicant (liquor/wine etc.)?
Do you suffer from sleeplessness?
Do you suffer from excessive urination?
Is your Urine color yellowish?
Do you feel any irritation or burning sensation while passing urine?
How is the flow of urine?  
How is your physique?
Are you diabetic?
If yes, mention sugar level in blood
in urine
Are you a patient of Hypertension?
If yes, mention your blood pressure e.g. 80/120
Have you suffered from any disease earlier?
If yes, name it
Do you feel palpitation of heart or pain in the chest or breathlessness during physical exercise?
Important :
If you have recently undergone a medical check-up pertaining to Sputum, phlegm, blood, urine or any X-ray, please mention the related reports
Any other problem that you might like to state
 

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Head Office

Matab Qureshi-Ul-Azeemi
Shop  # B-13, Sector 14-B, K.D.A.
Flats Phase IV, Main Road Shadman
Town # 2., North Karachi 75850
KARACHI-PAKISTAN
Contact: +92-21-32029191
+92-333-3066980
Skype: Qureshi Health Care

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