Health Questionnaire

Have you been feeling unwell? Please complete the Health Questionnaire below to tell us about your symptoms today and your health in general. This way, one of our doctors can assess your history to ensure that you get the appropriate care you need.

Please note that to use this service, you also need to pay for a consultation with one of our doctors. If you have not already done so, please click here to pay for a consultation with a doctor.

After paying for your doctor consultation, please click here to book a convenient date and time for your doctor appointment. PLEASE NOTE THAT THIS SERVICE IS NOT SUITABLE FOR MEDICAL EMERGENCIES!

Health Questionnaire

ABOUT THE PATIENT ie the person that the virtual consultation with a doctor is for

Patient's first name (required)

Patient's last name (required)

Patient's email address (required)

Patient's mobile number (required)

Patient's date of birth (required)

Is the patient allergic to any medication? (required)

List of medications, food or substances patient is allergic to? (if applicable)

What does the patient weigh? (required)

Does the patient take any medication regularly? (required)

List of medications the patient currently takes? (if applicable)

ABOUT THE PATIENT'S MEDICAL HISTORY

Has the patient undergone an operation in the last 30 days? (required)

Has the patient undergone an operation in the past ie more than 30 days ago? (required)

Has the patient had a medical diagnosis recently? eg malaria, ear infection or any other diagnosis (required)

Has the patient had a long term medical diagnosis? eg diabetes, renal impairment, liver impairment, HIV positive, sickle cell disease or any other diagnosis (required)

Has the patient conducted a lab test recently? eg malaria test, blood test or any other lab test (required)

If you have answered YES to any of the above option(s), please provide further details in the box below (if applicable)

ABOUT THE PATIENT'S SYMPTOMS TODAY

What symptom(s) has the patient been experiencing recently? eg cough, fever, headache (required)

What part(s) of the patient's body have been affected? (required)

How long has the patient been experiencing these symptom(s)? (required)

Or do you have a specific need? (required)

DELIVERY DETAILS ie where the prescription is to be delivered to

Street and house number (required)

District or Local Govt Area (required)

City (required)

State (required)

Country (required)

Is there anything we need to know? (if applicable)

Please upload a copy of any lab tests conducted or other necessary documents that might help your doctor during your virtual consultation (if applicable)
File limit 500,000 bytes; filetypes: jpeg, jpg, pdf, png, doc