IPC Heart Care Center
  You are here : Home > Medical Opinion
  
  
  

Need Medical Opinion from our doctors?
Fill the form given below to get medical opinions
GENERAL INFORMATION
* Name:
 Reference
* Age: * Sex:
* Date of Birth:    
* Postal Address: * Office Address:
* Telephone(R): * Telephone(O):
Mobile No: E-mail ID:
Occupation: Designation:
RISK FACTORS
1) Overweight / Obesity Yes No 7) Strong family History Yes No
2) High Blood Pressure Yes No 8) Smoking Yes No
3) Diabetes Yes No 9) Alcohol Yes No
4) Lack of Exercise Yes No 10) Raised Lipoprotein A level Yes No
5) Cholesterol / Triglycerides Yes No 11) Raised Homocystine Levels Yes No
6) Highly stressed Yes No 12) Depression Yes No
CURRENT SYMPTOMS
  YES/NO If Yes Details
Chest Pain Yes No
Fatigue Yes No
Breathlessness Yes No
Giddiness Yes No
Non-Cardiac Yes No
History Piles / Any bleeding tendencies Yes No
Heart Attack Yes No
Angiography Yes No
Angioplasty Yes No
Bypass Yes No
Others Yes No
RECENT INVESTIGATIONS
CBC/S. Calcium USG (KUB)
BUN / S. Creatinine X-ray chest
SGOT/SGPT 2D Echo
Other TMT
EXAMINATION
General Exam Chest
Pulse CVS
B.P. CNS
Other P/A
CURRENT MEDICATIONS
1. 6.
2. 7.
3. 8.
4. 9.
5. 10.
WORD VERIFICATION
  Word Verification ASP CAPTCHA Generator  
Type the characters you see in the picture.
  
 


© IPC Heart Care Pvt. Ltd.          Website Designer: Webcraft (Mumbai)  
Resources