20201009 UPDATED FINAL TELEMEDICINE REQUESTS TO SAMATVAM MEDICAL HISTORY FORM

NAMASTHE……….. Dear Friend Family Prayers Best Health.

PLEASE COMPLETE THIS QUESTIONNAIRE AND SEND IT, ALONG WITH ALL
ATTACHMENTS REQUESTED TO THE FOLLOW EMAIL ID, AS SOON AS POSSIBLE.
samatvamtelemedicine@gmail.com
This will help us to review your details ahead of time and serve you in much stronger
ways. Many thanks for your cooperation and support. Please complete the following
MEDICAL HISTORY FORM and send it to us VIA EMAIL, to help us serve you better. [Also,
please attach as PDF only - your (a) Samatvam Note Book; (b) latest prescription; (c) latest
blood, imaging and other diagnostic reports; (d) latest health monitoring logs – blood
glucose, blood pressure, weight etc; (e) Hospital Discharge Summaries if any; (f) Any other
health document
[Please note that each pdf cannot exceed 5 mb in size]
=========================================================================
REFFERED TO SAMATVAM BY [Please give names]:
Doctor: Relative / Friend:
Website: Others:
=====================================================================================
A: PATIENT NAME:
B: AGE [YEARS] ; DATE OF BIRTH: SEX: [ ]MALE; [ ] FEMALE
C: MOBILE NUMBERS:
D: ADDRESS

E: PATIENT EDUCATION: OCCUPATION:

G: FAMILY DETAILS
NAMES RELATIONSHIP EDUCATION OCCUPATION
Father
Mother
Husband
Wife
Son 1
Son 2
Daughter 1
Daughter 2
Others

Contact Person(s) in the Family for Telemedicine Consultations [Able to use Computer and Smart
Phones etc]: Names and Mobile Numbers

Notes: Please mention any other special requirements and challenges, to enable Samatvam Medical
Team to try to serve your family in the best possible ways:

G: REASONS FOR THIS MEDICAL CONSULTATION (PLEASE LIST ALL YOUR CURRENT MEDICAL PROBLEMS
WITH DURATION. HOW LONG?)
1.
2.
3.
4.
5.
6.

H: PAST MEDICAL HISTORY (PLEASE LIST ALL YOUR PREVIOUS HEALTH CHALLENGES.... DISEASES,
SURGERIES ETC WITH YEAR)
1.
2.
3.
4.

I: LIST OF CURRENT MEDICINES YOU ARE TAKING

1.
2.
3.
4.
5.
6.

J: FAMILY HISTORY OF DIABETES, HIGH BLOOD PRESSURE, HEART DISEASE, KIDNEY DISEASE, THYROID
PROBLEMS ETC, WITH RELATIONSHIPS
1.
2.
3.
4.

K: YOUR QUESTIONS TO SAMATVAM JNANA SANJEEVINI MEDICAL TEAM

1.
2.
3.
4.

L: SUMMARY OF HEALTH MONITORING DATA AND LATEST BLOOD REPORTS WITH DATES.

Date Height Weight Blood Blood Blood Blood Blood Blood Blood
Cms Kgs Glucose Glucose Glucose Glucose Glucose Glucose Glucose
Before After Before After Before After 3 am
Breakfast Breakfast Lunch Lunch Dinner Dinner

Date Fasting Post HbA1c Serum Total HDL LDL Trigly Urine TSH
Blood Prandial Creat Chole Chole Chole cerides Alb
Glucose Blood inine sterol sterol sterol Creat
Glucose Ratio

VERY IMPORTANT: ALL SERVICES BY PRIOR APPOINTMENTS ONLY

APPOINTMENTS FOR CLINIC VISITS, TELECONSULTATIONS, LABORATORY SERVICES, PHARMACY SERVICES
AND HOME CARE: Please call: •Ramakrishna: 9448350728; •Rajeshwari: 9964235162; •Prakash:
9986927607; •Sudhakar: 9060008806; •Anupama: 9972450447; •Srilatha: 9448374248
Please also call and re-confirm your visit / services requested a day before.
EMERGENCIES: PLEASE IMMEDIATELY REPORT TO NEAREST HOSPITAL AND OBTAIN CARE.

Thank You – Respects – Best Health

Samatvam: Science and Research for Human Welfare Trust
Jnana Sanjeevini Diabetes Hospital and Medical Center
2, 1 A Cross Marenahalli, JP Nagar Phase 2; Bangalore 560078, India
Phone: 91 - 80 - 26493040, 26493060;