Self-assessment of health questionnaire

Full Name

Birth Date

Phone

Email address

Please fill-out this form.

Your doctor will analyze the information and test results and provide you with a conclusion or schedule an appointment.

Reasons for visiting a doctor

Please indicate your complaints

Do you suffer from any chronic diseases

Yes

What medications do you take regularly?

What surgeries have you had?

Describe your expectations from the visit:

Relief of pain/fever/shortness of breath/limited movement

Comments on test results

Prescription of treatment

Assessment of treatment course

Second opinion on condition

Relief of acute condition

To get registered

To get medications within the state program

Referral to hospital

Tick on the boxes that indicate how you have felt over the past 30 days.

Illnesses of family members

If you have undergone any examination outside of "Vardanants" NPC in the last 30 days, please attach the answers. Take a picture of them with your phone and attach them as an attachment.