Kalra Hospital and SRCNC Sri Ram Cardio - Thoracic and Neurosciences Centre

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Kalra Hospital & SRCNC

We at Kalra Hospital endeavour to bridge with the patients in a unique way. Our Consultation Questionnaire in an initiative to bring the specialist doctors and patients closer with more clarity. You may clearly specify the details here and out team of experts shall respond to your queries, promptly.

The Online Consultation Questionnaire

(*represents compulsory fields)

Patient Details

Check here if delivery details is same as billing details

Last Name:
*First Name:
Middle Name:
E-mail Address:

Street Address1:

Street Address2:

City:

State:

Zip Code:

Country:

Phone:

Country
Code

Area
Code

Phone
Number

*Age
*Sex:
*Life Stage:

*Marital Status:
Occupation:

* Chief Complaints (with duration)

* History of Present Illness

(Elaboration of chief complaints, with mention of general symptoms of disease, viz. history of loss of appetite, weight loss, history of bladder, or bowel abnormalities)

* Treatment History

(With elaboration of details of previous treatment undertaken)

Family History

(Any significant family history of disease, related to current chief complaints)

* Past History

Please select Yes or No wherever applicable; if Yes please provide more information in the adjacent text area, e.g., if suffering from hypertension, select Yes, and enter recently recorded blood pressure reading(e.g. 120/80 mm Hg)

Arthritides:

Yes No

Asthma:

Yes No

Diabetes Mellitus:

Yes No

Dyspepsia:

Yes No

Heart Disease:

Yes No

Hypertension:

Yes No

Tuberculosis:

Yes No

Exposure to STD (sexually transmitted disease):

Yes No

chronic disease

Yes No

Jaundice:

Yes No

History of Trauma or Injury:

Yes No

History of Surgery:

Yes No

History of Gynaecological disease (for women):

Yes No

History of any other disease(s) not mentioned above:

Personal History

Non vegetarian?

Yes No

Do you take any Medicines?

Yes No

Drug(s) Details :

Do you have a history of smoking?

Yes No

Duration	(in years)

Number of cigarette(s) or pack(s) per day

Do you have a history of consuming alcohol?

Yes No

Alcohol Type

Duration	(in years)

Alcohol intake per day

Do you have history of chewing tobaco?

Yes No

Duration	(in years)

Do you have a history of allergy(s)?

Yes No

Allergy(s) details :

Any other habits?

Attach soft copy(s) of other report(s) (if any)

Report 1

Report 2

Report 3

Report 4

Report 5

Report 6

Billing Details (Sender's Information)

Last Name:

*First Name:

Middle Name:

*E-mail Address:

Organization:

*Phone:

Country
Code

Area
Code

Phone
Number

Fax:

*Street Address1:
Street Address2:
*City:
State:
*Zip Code:
*Country:

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