Patient Health Assessment | Dr Onn Akbar Ali

1

Personal Information

Full Name *

Please enter your full name

IC / Passport Number *

Please enter your IC or passport number

Phone Number *

Please enter your phone number

Email Address *

Please enter a valid email address

2

Past Medical History

Do you have any of the following conditions? *

High Blood Pressure Diabetes High Cholesterol High Uric Acid / Gout Stroke Kidney Disease Asthma None of the above

If you have high blood pressure, how long have you had it?

Past illnesses or surgeries

Family history of heart disease? *

Yes No Not sure

Please select an option

3

Lifestyle

Smoking *

Yes No Ex-smoker

Please select an option

Vaping *

Yes No Ex-vaper

Please select an option

Alcohol Consumption *

Yes No Occasionally

Please select an option

Do you take any health supplements?

Yes No

If yes, please list your supplements

4

Current Medications & Allergies

Current Medications

Do you have any drug allergies? *

Yes No Not sure

Please select an option

Please describe your allergies and reactions

Previous Surgeries

5

Reason for Consultation

Please specify

6

Supporting Documents

Upload supporting documents (Optional — max 5 files)

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Drag & drop files here or click to browse

PDF, DOC, DOCX, JPG, PNG — Max 10MB per file

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Assessment Submitted Successfully

Thank you for completing your health assessment. Dr Onn Akbar Ali's team will review your information before your appointment.

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