PATIENT INPUT FORM
Our Data Privacy is inspired by HIPAA ( Health Insurance Portability and Accountability Act of 1996). Whatever information is captured here is confidential between you and MYHEALTHSMB and will not be disclosed to anyone other than you. The purpose to capture this information is only for Diagnosis purposes
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Email *
Which Country you Live In *
Mobile Number *
Name the city you live in *
Patient Name *
Date of Birth (Actual) *
MM
/
DD
/
YYYY
Gender *
Are you a *
Smoking/Chewing *
Drinking *
Are you *
Are you *
Your Weight (Kgs) *
(Actual in number like 50 or 60 or 70)
Your Height (Cms) *
(Actual height in number like 155 or 165 or 170 or 184 or 195)
Blood Group *
Activity Level *
What is your profession *
What is your Blood Pressure (Please mention like Sys/Dys - 120/80) *
What is your Heart Rate *
Have you gone through any Dental treatments till now in your life *
Captionless Image
Required
Do you have a black ring around your neck and or have cracked heals like shown in the image? *
Captionless Image
Do you have any scars (stiches) after an injury or surgery etc. *
Required
Do you have any known situations that are causing you continous stress *
Required
Any trauma that you have gone through that is still hurting you (For e.g accident, loss of near one and you are unable to forget, etc) *
Required
If you have answered "Yes" above, Please briefly mention what it is
Do you have any known Genetic issues (Like Diabetes, Cardiovascular, etc.) *
If yes, please tell us what Genetic Issue do you have
Do you have any known Allergies (Diary, Wheat, Peanut, Egg, Magnesium, Iron, etc.) *
If yes, please tell us what Allergies do you have
Are your hands and feet *
Normal temp
Cold
Hot
Cold & Sweat
Hot & Sweat
Normal & Sweat
Hands
Feet
How do you react to stress? *
How do you handle changes in weather? *
How do you sleep? *
What is your energy level like? *
How do you handle emotions? *
How do you respond to criticism? *
How do you deal with confrontation? *
How do you approach decision-making? *
What type of food do you crave? *
How do you react to grief or loss? *
How do you handle responsibility? *
How do you deal with change? *
How do you respond to authority? *
How do you handle disappointment? *
How do you cope with failure? *
How do you express love? *
How do you handle criticism of your work? *
How do you approach conflicts in relationships? *
How do you deal with physical pain? *
How do you feel about routines? *
How do you handle surprises? *
How do you feel about social gatherings? *
How do you approach new challenges? *
How do you handle setbacks? *
How do you deal with injustice? *
How do you handle financial matters? *
How do you deal with loneliness? *
How do you react to criticism of your appearance? *
How do you handle disappointment in others? *
How do you deal with regrets? *
How do you respond to unexpected challenges? *
How do you approach spirituality? *
How do you handle betrayal? *
How do you deal with boredom? *
How do you approach learning new things? *
Top Three health issues you are facing?
 *
(Health issues like Diabetes, Heart Issues, Kidney problem Pains, etc.)
Can you correlate if your health problem started after for e.g a dental treatment, an injury or accident or after an emotional episode or set back? *
If yes, provide details
Which Covid Vaccine shots have you taken *
Where you infected by Covid? *
Are you on any medication today? Please mention all the medicines you are taking *
(Like medicines, contraceptives, hormone therapy, etc.)
A copy of your responses will be emailed to the address you provided.
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