Register Yourself

Name
Date
Address
Age
Sex
- Male
- Female
Phone
Email
Marital Status
- Married
- Engaged
- Single
Occupation
Birthday
Anniversary
Brief description of your concern
How did you find us ?
- Practo
- Facebook/Twitter/Instagram
- Friend/Relative
- Our Website
- Walk in
- Others
Have you ever been treated by a Dermatologist?
If yes, please provide details
- Yes
- No
Diagnosis
Treatment given
Medical history
H/o Diabetes, High blood pressure, Heart disease
- Yes
- No
If yes, Please provide details of medication
Do you smoke?
- Yes
- No
Do you consume alcohol?
- Yes
- No
Are you Pregnant?
- Yes
- No
Are you lactating?
- Yes
- No
H/o PCOD
- Yes
- No
Are you on Aspirin/Evion/Vit E
- Yes
- No
Any drug allergies
Have you had a cough in the last 10 days?
- Yes
- No
Have you had a fever in the last 10 days?
- Yes
- No
Have you had shortness of breath in the last 10 days?
- Yes
- No
Have you been in contact with anyone who has been infected, suspected or diagnosed with COVID-19?
- No
- Yes
Have you been tested positive for COVID-19 ?
- Yes
- No