Aventus Medical Care, Inc.

Teleconsult Online Form

INSTRUCTIONS:

Please check your information before proceeding to the next page.

Items marked with asterisk * are mandatory.

DISCLAIMERS:

YOUR MEDICAL HISTORY IS IMPORTANT TO US. Intentional concealment of relevant information or refusal to cooperate by persons affected by a health event or public concern is a crime under the REPUBLIC ACT NO. 11332.

Online consultation, including medical advice, is solely based on the information provided by you and/or your physician, if any, and, in the absence of a physical evaluation, the TelAventusMD physician may not be aware of certain facts that may limit or affect his or her assessment or diagnosis of your condition and recommended treatment. The Online consultation is very different from a regular face-to-face examination and that the TelAventusMD physician providing the consult is limited by the written information and imaging, if any, provided by you. Accordingly, the diagnosis you will receive is limited and provisional and an online consult is not intended to replace a full medical face-to-face evaluation by a physician.

1. Personal Information

2. COVID-19 Screening

3. Past Medical History

4. Family History

5. Other Information

1. Personal Information

Chief Complaint:

First Name:

Middle Name:

Last Name:

Date of Birth

Age

Sex:

Civil Status

Telephone Number:

Mobile Number:

E-mail Address:

House Address:

Work Information:

Company:

Occupation:

3. Past Medical History

Illness	Yes / No	Remarks
Hypertension
Diabetes Mellitus
Heart Disease
Asthma
Hepatitis
Tuberculosis
Pneumonia
Thyroid disease
Kidney disease
Cancer or Mass
Measles
Chickenpox
Mumps
Dermatologic disease
Congenital disease
Operations
Hospitalization
Others(if any)

4. Family History

Illness	Yes / No	Remarks
Hypertension
Diabetes Mellitus
Heart Disease
Asthma
Lung Disease
Kidney Disease
Liver Disease
Thyroid Disease
Cancer
Rheumatism
Others(if any)

5. Other Information

Allergies:

Food Allergies:

Medication Allergies:

Personal and Social History: Please note for the frequency and duration.

Smoking HX:

# of sticks per day:
# of weeks / years:
Occasional:

Drinking Alcohol Beverage HX:

# of bottles or shot:

Frequency:

Kindly click if patient is MENOPAUSE.

OB GYN History:

LMP: Last Menstrual Period
PMP: Previous Menstrual Period
Interval:
Duration:

Contraceptive Use:

Oral:
Injectable:
Date Last Given:

Pregnant:

AOG:

OB Score:

Gravida: number of times you are pregnant
Para: number of times you have given birth with gestational age of 24 weeks or more regardless of whether child is born alive or is stillborn
Term births: number of babies born greater than or equal to 37 weeks
Preterm births: number of babies born less than or equal to 37 weeks
Abortions: number of terminated pregnancies that did not result in the birth of a child
Living Children: number of babies born regardless of duration of pregnancy

History of Delivery:

NSD:
CS:
Indication:

Contact UsRoom 301, 3rd Floor Comfoods Building, Sen. Gil Puyat Avenue cor. Chino Roces, San Antonio, Makati City 1203
(02) 840-0588
inquiry@aventusmedical.com
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