Application Form - Participants for Digital Management of Hypertension and Diabetes Programme (SIHAT)
By submitting this application form, you agree and consent to your personal data which you provide to Health Digital Technologies Sdn Bhd [Registration No: 201601014465 (1185396-D)] (“DoctorOnCall”) in this form being processed, collected, used, disclosed and/or retained by DoctorOnCall and the relevant parties for the purposes of administering the above-mentioned programme.

The submission of this application form will not automatically enroll you into the above-mentioned programme. We will contact you via phone call, messages, and/or email in the case of successful application.

Jika anda ingin melengkapkan borang permohonan ini dalam Bahasa Melayu, sila layari pautan ini: https://forms.gle/9ZwArW1PDnFghKEUA
Sign in to Google to save your progress. Learn more
Email *
Full name (as per IC) *
Date of birth *
MM
/
DD
/
YYYY
Gender *
Race *
Phone number *
Residential address *
Please provide full address including the postcode, city and state.
Monthly household income *
Types of non-communicable diseases being diagnosed *
Please check all the relevant items.
Required
Are you on long term medication or follow up? *
If yes, please provide more details in the next question (e.g. type of long term medication or the reason of long term follow up etc.).
Please provide more details of your long term medication / follow up.
When was the last time you take the HbA1c test?
MM
/
DD
/
YYYY
What was the reading from your latest HbA1c test?
The answer should be in "%", e.g.  6%
When was the last time you have your blood pressure check?
MM
/
DD
/
YYYY
What was the reading from your latest blood pressure check?
The answer should be in "systolic / diastolic mmHg", e.g. 120/80 mmHg.
What are your preferred languages for communication? *
Please check all the relevant items.
Required
This is a coaching programme which requires active participation and regular communication with the health care providers via phone calls / messages / video calls. Are you comfortable with these arrangements? *
Are you comfortable with using mobile devices, software applications and any other relevant technology that is required during the programme?   *
Participant Acknowledgement: Please note that this programme provides the items mentioned on the programme website (https://www.doctoroncall.com.my/health-centre/sihat) for free, based on a budget and the monitoring schedule that is set for each participant. In the event that the participant wishes to conduct more frequent monitoring (outside of the suggested schedule) and/or is prescribed with more advanced medications, participant is required to cater for the extra costs. *
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Health Digital Technologies. Report Abuse
Google Forms