Test page

Sex *

MaleFemale

Past history

Does the patient have high blood pressure *

YesNoI Do not know

Does the patient have Diabetes *

YesNoI Do not know

Has the patient ever been treated for a stroke *

YesNoI Do not know

Has the patient ever been treated for ischaemic heart disease/ heart problem *

YesNoI Do not know

Any other major illness

List of current medications and dosages

Drug allergy
 
YesNoI Do not know

If yes, names of drug

Famil​y history of

 

Cancer

YesNoI Do not know

High blood pressure

YesNoI Do not know

Diabetes

YesNoI Do not know

Does the patient smoke or use toabacco

YesNoI Do not know

Questions you would like answered ?

Current problem / symptoms ?

Does the patient drink alcohol   YesNoI Do not know

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