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Date:________________________________ Patient Name:________________________ Referred by:_________________________ Mailing Address:_____________________ Telephone:___________________________ Your Email Address:__________________ Date of Birth:_______________________ Gender: Male Female Primary Care Physician Name, Address and Phone:__________________ Emergency Contact Name:______________ Relationship:________________________ Phone:_______________________________ Your Height:_________________________ Your Weight:_________________________ What seems to be the problem? What is the reason for consultation? Do you have any of these symptoms? Check all that apply to you. Gastrointestinal Symptoms:
_____ Nausea _____ Vomiting _____ Heartburn _____ Regurgitation _____ Difficulty Swallowing _____ Painful Swallowing _____ Change in Bowels _____ Diarrhea _____ Constipation _____ Bloody Stools _____ Black Stools _____ Abdominal Bloating _____ Excess Belching _____ Excess Flatus _____ Jaundice _____ Weight Loss _____ Poor Appetitie
_____ Shortness of Breath _____ Coughing up Blood _____ Chest Pain _____ Palpitations _____ Easy Bruising _____ Easy Bleeding _____ Blood in Urine _____ Painful Urination _____ Difficulty Urinating _____ Weakness Arm/Leg _____ Numbness Arm/Leg _____ Blurred Vision _____ Severe Headache _____ Fever/Chills I used a search engine I typed the address directly into the web browser I linked from an email I came from another site (Please specify) Other (Please specify) What is the primary goal of your visit to qureshiuniversity.com today? Please select the most appropriate answer from the list below. Look for general treatment/therapeutic information Research product-specific information Look for conferences and events Compare products/treatments Look for clinical information Contact Qureshi University Other (Please specify) Overall, how successful were we in enabling you to accomplish your primary goal during today's visit? Extremely Successful Successful Unsuccessful Extremely Unsuccessful Which of the following best describes you? I am a medical student I am a Resident I am a Fellow I am a physician I am a nurse I am another type of medical professional I am an administrator within a health care practice or hospital I am a prospective patient I am a member of the media Other (Please specify) These are basic questions. There are many more. |