Username or email *
Password *
Remember Me
Log in
Step 1: Personal Information
Your Full Name:
Your ID/Passport number:
Date of Birth (DOB):
Age:
Your cell number:
Your email address:
Medical Aid:
Medical Aid Plan Option:
Medical Aid Membership Number:
Emergency Contact Name:
Emergency Contact ID:
Emergency Contact Cell Number:
Emergency Contact Email Address:
Step 2: Personal Medical Information
Do you smoke?
Do you consume alcohol?
Any allergies?
Previous infections?
Immunizations?
Any surgical operations?
Any chronic medication?
Any other supplements?
Any other medical conditions?
Step 3: Family History
Family History of Heart Disease?
Family History of Cancer?
Family History of Stroke or Heart Attacks?
Family History of Diabetes, Blood Pressure, and any other medical conditions?
Step 4: Additional Questions
When was the first day of your last normal menstrual period? (for women):
On contraception or HRT currently?
Last Pap smear?
Last mammogram?
Last bone density test?
Last prostate examination?
Step 5: Social Information
Your occupation:
Do you exercise or play sports?
What are your passions or hobbies?
What are your main concerns that you would like to address during this consult?
Previous stepNext step