Appointment reason Please enable JavaScript in your browser to complete this form.Patient name *Names and dose that the patient takes regularly *Has the patient any allergy? *Not that I know ofYesHas the patient been hospitalized in the last 3 months? *YesNoSymptoms *I rather not informHipertension (pressão alta)Pain in the chestDiarrheaNausea / vomitsDifficulty to urinateDifficulty to breathSweating excessivelyHigh fever ( >38o.C)Excessive thirstNodule (lump)HeadacheItchinessAbdomen seems swollenChanges in weight and appetiteOther symptom(s)For how long the patient has been having these symptom(s)? *2 last daysSince last weekSince last monthFor less than 3 months agoFor more than 3 months agoDon't know / don't rememberAdditional medications taken in the last 2 weeks *What were the reasons that made you look for an appointment? *Additional notesSend If you need assistance, please send a mail to research @ globeperson.com