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Name *

First

Last

Date of Birth

Gender

• Male
• Female
• Others

Marital Status

• Single
• Married
• others

Email Address *

Phone No.

Emergency Contact Information: Name and contact number

Phone Medical and

1. Do you have any known allergies?

• Yes
• No
• If Yes, Please List

2. Do you have any current medical conditions?

• Yes
• No
• If Yes, Please List

4. Do you have any past surgeries or hospitalizations?

• Yes
• No
• If Yes, Please List

5. Smoking

• Yes
• No
• If Yes, Per day

6. Alcohol:

• Yes
• No
• if Yes (How much per week in units)

7. Family Medical History: (Tick if applicable)

• Diabetes
• Hypertension
• Heart Disease
• Cancer
• Others (Please specify):

Submit

I, the undersigned, confirm that the information provided above is accurate and up to date. I consent to the medical evaluation and treatment by the healthcare professionals at Dr Arshad Health Associates. I understand that my medical information will be kept confidential according to clinic policy.