Dear customers, please fill in your contact information to facilitate our communication with you and answer all your questions to evaluate and diagnose your case and contact you. Note: If you are complaining of two diseases at the same time, please include both in the “Others” choice. Do you suffer from chronic diseases? High blood pressureDiabeteshigh lipid levelsRheumatismRespiratory and Asthma diseasesnoneother diseases Are you on prescribed medications? (Mention their names if available) YesNo Note: If you are complaining of multiple symptoms, please include them in the “Others” choice. Do you suffer from one of the following symptoms? Dizzinessbone painhair lossasthenianumbness of the extremitieslethargy and fatigueswelling in the lower extremitiesnoneother symptoms You Name Mobile number Gender malefemale Age
