Adult Physical & Mental Health Scan

Patient Name (required)

Age

Gender
Select GenderMaleFemaleOther

Email Address (required)

Phone Number (required)

City / Location

Chief Complaint – Main Health Problem (required)

How long have you had this problem?

Aggravating & Relieving Factors

Any Past Illnesses / Surgeries / Hospitalisations

Family Medical History

Current Medications (if any)

Allergies (food, drug or environmental)

Sleep Pattern
SelectNormalDisturbed – difficulty falling asleepDisturbed – wakes up at nightExcessive sleepiness

Appetite & Digestion

Any Additional Information for Dr. Gaba