Teleconsultation Booking
Health Assessment
Understanding your current health status helps you identify potential risks, personalize your consultation, and ensure safe and effective wellness recommendations.
Personal Details:
Your Full Name
Your Age
Gender
Female
Male
Others
Contact Information:
Email Address
Mobile Number
Physical Parameters:
Height (in feet)
Weight (in kg)
Section 1: Your Current Medical Condition
Enter your chief medical concern
(Enter what is most concerning OR specify no concerns)
Do you have any pre-existing medical conditions?
(Select all that apply)
Obesity
Diabetes
Osteoporosis
Hormonal Imbalance (PCOS, Thyroid, etc.)
Severe Period Cramps
Post-Menopausal Issues
None
Have you ever been diagnosed with any of the following conditions?
(Select all that apply)
High Blood Pressure
High Cholesterol
Autoimmune Disorders
Cancer (Current or Past)
None
Do you have a family history of cancer
(especially cervical, breast, ovarian, or prostate cancer)?
Yes
No
Section 2: Lifestyle, Diet & Risk Factors
Do you smoke or consume tobacco in any form?
Yes
No
Do you consume alcohol?
Regularly
Occasionally
No
Do you follow a regular exercise routine?
Yes, daily
Occasionally
No, not regularly
How would you describe your diet?
Balanced (includes fruits, vegetables, proteins)
High in processed/junk food
Vegetarian
Vegan
Non-Vegetarian (Includes lean meat like chicken and fish)
Non-Vegetarian (Includes red meat frequently)
What are your staple dietary preferences?
(Select all that apply)
Wheat (Chapati/Roti)
Multigrain
Jowar / Bajra
White Rice
Brown Rice
Pulses (Dal, Beans)
Sambhar
Leafy Vegetables
Egg (Boiled/Omelette)
Lean Meat (Chicken/Fish)
Red Meat (Mutton, Beef)
Poha / Upma / Oats (Breakfast)
No Specific Preference
Do you follow a specific regional or cultural diet style?
North Indian
South Indian
Gujarati
Marathi
Goan
Mangalorean
East Indian
Others
No specific preference
How do you usually plan your meals?
I manage my meals personally, so you can recommend an individual diet plan
I prefer a family-inclusive plan that suits everyones meals at home
Do you experience frequent digestive issues, bloating, or gut health problems?
Yes
No
Section 3: Menstrual & Reproductive Health
(For Women Only)
Do you experience irregular periods or severe menstrual cramps?
Yes
No
Have you been diagnosed with PCOS, endometriosis, or any reproductive health issues?
Yes
No
Are you currently undergoing any hormone therapy or using birth control pills?
Yes
No
Have you received an HPV vaccine?
Yes
No
Section 4: Side Effects & Precautions Awareness
Do you have any known allergies to supplements, herbs, or medications?
Yes (Please specify)
No
Are you currently on any long-term medications?
(e.g., blood thinners, insulin, steroids, antidepressants etc.)
Yes (Please specify)
No
Do you have kidney or liver-related conditions that may require dosage adjustments?
Yes (Please specify)
No
Submit