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Annual Health Check
Screening Test Advisory
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Post-Operative Review and Advisory
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Home
About us
What We Do
About Medical Director
Medical Director’s Message
Our Services
Annual Health Check
Screening Test Advisory
Medication Review
Blood Test and Clinical Investigations Review
Pre- Operative Review and Advisory
Post-Operative Review and Advisory
Service Plan
Contact
Book Appointment
Menu
Home
Schedule Appointment
Schedule Appointment
Patient Information
First Name
*
Last Name
*
Other Name
Gender
*
--Select--
Male
Female
Email Address
*
Phone
*
Date of Birth
*
Address
Current Medical Concern
*
Annual Health Advisory
Screening Test Advisory
Medication Review
Chronic Illness Review
Blood Test and Clinical Investigations Review
Pre-Operative Review and Advisory
Post-Operative Review and Advisory
Second Opinion on Clinical Management
Others
Other Current Medical Problems
*
Chronic Medical Conditions
Condition
Year Diagnosed
Additional Information
Past Surgical History
Surgery
Date
Outcome/Complication
Medication Records
Medication Name
Dosage
Frequency
Reason for Use
Over-the-Counter Medications/Supplements:
Allergies (Medication, Food, Environmental):
*
WHO Functional Status
*
Fully active, able to carry on all pre-disease activities without restriction
Restricted in physically strenuous activity but ambulatory and able to carry out light work
Ambulatory and capable of all self-care but unable to carry out any work activities
Capable of only limited self-care, confined to bed or chair for more than 50% of waking hours
Completely disabled, cannot carry on any self-care, totally confined to bed or chair
2. Activities of Daily Living (ADLs)
Bathing
*
Independent
Assistance needed
Dependent
Dressing
*
Independent
Assistance needed
Dependent
Toileting
*
Independent
Assistance needed
Dependent
Mobility
*
Independent
Assistance needed
Dependent
Feeding
*
Independent
Assistance needed
Dependent
Managing medications
*
Independent
Assistance needed
Dependent
Shopping
*
Independent
Assistance needed
Dependent
Cooking
*
Independent
Assistance needed
Dependent
Housekeeping
*
Independent
Assistance needed
Dependent
Transportation
*
Independent
Assistance needed
Dependent
Living Situation
*
Alone
With family
Assisted Living
Nursing home
Support System
*
Smoking History
*
Never
Former
Current
Alcohol Use
*
Select Service Plan
*
--Select--
Silver
Gold
Peri-Op
Subscription plan
*
--Select--
Monthly
Annually
Do you need any Additional Service?
*
Yes
No
Additional Service
*
Second Opinion on Clinical Management
Home Visit
Silver (Yearly)
£120 yearly
£120 yearly
Silver (Monthly)
£10 Monthly
£10 Monthly
Gold (Yearly)
£180 yearly
£180 yearly
Gold (Monthly)
£15 Monthly
£15 Monthly
Pre-Op
£250/Operation
£250/Operation
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