CRD Health :: Appointment

Please Enter Patients Details

Fill the form below and submit your query we will contact you as soon as possible.

Full Name *
Date of Birth *
Day Month Year
Occupation *
Gender *
Address *
Street Address Street Line 2 City State / Province Postal / Zip Code Country
Mobile Number *
E-Mail Address *
Are you *
Height in cms *
Weight in kg *
Waist in cms *
Knee pains:
Yes / No
Breathlessness on walking:
Yes / No
Sleep Timing *
From PM to am
Quality of sleep *
Do you have diabetes? *
If yes – for how many years? Send all your past investigations and current treatment Details separately.
Do you have hypertension (high/BP)? *
If yes – for how many years? Send all your past investigations and current treatment Details separately.
Do you have any other disease?
Any history of surgery/ medical procedures you have undergone in the past
Do you understand that for optimum results, you will have to comply with doctor’s guidelines & instructions? *
Why do you want to lose weight?
Why do you want to reverse your diabetes?
Why do you want to reduce hypertension (increased BP)?
How serious and determined you are in your decision on a scale from 0 to 10 where 0 means the least serious and 10 means very serious (Which Effectively means 100% compliance with doctor’s instructions).
You need two things to get optimum results
A. A strong reason- your reason has to be stronger than your excuses.
B. 'Stick' Ability – Stickability
It is the best ability. The ability to stick to the diet program till you achieve optimum results. Do you have these two things in you? *
Please send your front and side full picture. *