Contact us

• For medical issues use this form

• Full Name *
  First Name Last Name
• Are you male or female? *
  Please state
• Your age
• Your location
• Phone Number
  - Area Code 260 Phone Number
• Check the conditions that apply to you or to any members of your family or relatives:
  Asthma Cancer Cardiac disease Diabetes Hypertension Psychiatric disorder Epilepsy
• Type all the problems that apply to you or family member
  Type Example Diabetes, Asthma. Etc.
• Check the symptoms that you're currently experiencing:
  Chest pain Respiratory.(cough,difficult breathing,chest congestion etc) Heart disease Cardiovascular Hematological Lymphatic Neurological Psychiatric Gastrointestinal.(diarrhea,stomach pains,vomiting,heartburn,nausea etc) Genitourinary.(Discharge or pain from penis or vagina) Weight gain Weight loss Musculoskeletal.( muscle pains,backache etc) Headache Fever (body temperature high)
• Write all that applies to you.
• Are you currently taking any medication?
  Yes No
• Type Yes or No
  If YES type example: Quinine
• Do you have any medication allergies?
  Yes No Not Sure
• Type Yes or No
  If Yes then which medication.
• Do you use or do you have history of using tobacco? *
  Yes No
• Do you use or do you have history of using illegal drugs? *
  Yes No
• How often do you consume alcohol?
  Daily Weekly Monthly Occasionally Never
• Type what applies
  Type example monthly
• Explain your problem to a Doctor, including the duration since it started. e.g headache for 2 days
• Should be Empty:

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