Patient Medical History Form

Personal Information

• Name: Bernardo Cua
• Age: 62
• Gender: Male
• Contact Number: 09296431831
• Email Address: bernardocua@gmail.com

Medical History

• Primary Health Conditions:

• Diabetes: Condition onset at age 50
• Hypertension (High Blood Pressure): Condition onset at age 50

Secondary Complaints/Symptoms:

• Chest Pain
• Elevated Blood Glucose Levels
• Gastrointestinal Issues
• Medication

Current Medications:

• Omeprazole
• Metformin
• Medication Allergies: None

Lifestyle

Tobacco Use: Yes (Marlboro Lights)

Illegal Drug Use: No

Alcohol Consumption: Occasionally

This form is intended to provide information regarding the patient's medical history, Bernardo Cua. The data is self-reported and needs to be evaluated by a healthcare professional to diagnose and treat any health conditions.

It is crucial to update this form regularly to reflect any changes in the patient's medical condition, lifestyle, and medications for accurate medical records.

Patient signature:______ Date:________ Doctor/Nurse signature:_______ Date:________

Online Doctor Appointment Request Form

Personal Information

Name: Adrian Manasan

Date of Birth: October 28, 1971

Gender: Male

Phone Number: 09458102657

Address: 10 Lopena Area 4, Sunrise Paranaque, Metro Manila, 1715

Email Address: adrianm@gmail.com

Previous Interactions

Have you ever applied to our facility before? No

Appointment Details

Department Requested: Radiology

Thank you for choosing our healthcare services. Our staff will reach out to you via your provided contact details to confirm your appointment and provide you with further instructions. Your personal information is protected and will be used strictly for the purpose of your medical care.

Applicant signature:______ Date:________ Verification Officer:_______ Date:_________

Please note: Online appointments should be requested at least 48 hours in advance to allow for processing. If you require immediate medical attention, please call our emergency services number.