ART REMOTE EXAM – Dr. Alim

ART REMOTE EXAM

Date of Exam:

Examiner:

GENERAL INFORMATION

Name

Date Of Birth

Age

Sex:

Marital Status:

Number of Children:

Occupation:

Address:

Shipping Address:

Email

Phone:

CLINICAL INFORMATION

Weight:

Height:

Meals per Day:

Constipation:

Type Diet:

Alcohol:

Tobacco:

Tobacco:

Recreational Drugs:

Prescription Drugs:

Medical Devices used:

List Health Goals:

2

3

Your Chief Complaint:

Dont repeat what other told you about yourself

Current Treatment:

Major Past Illnesses History

Surgeries:

Covid19 Vax Status: