Virtual Doctor

Name:

Age:

Gender:

Male Female Other

Height (cm):

Weight (kg):

Current Symptoms:

Fever Cough Headache Fatigue Nausea Shortness of Breath

Medical History:

Diabetes Hypertension Heart Disease Asthma Allergies

Dietary Preferences:

Do you smoke?

Yes No

How often do you exercise?

Any additional comments?

Health Check-Up Form