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What type of Diagnostic Package do I need?

  • How old are you?: **

  • Your gender is: **
     Male       		  Female

  • Do you smoke cigarettes? **
     Yes       		  No


Do you have the following symptoms? Do you have the following history?
    Heart Related
  • Chest Pain
    		•  :    Yes   
  • Chest Tightness
    		•  :    Yes   
  • Palpitation
    		•  :    Yes   
  • Shortness of breath
    		•  :    Yes   
  • Throat Tightness
    		•  :    Yes   
  • Numbness of left hand
    		•  :    Yes   
  • Epigastric discomfort
    		•  :    Yes   
  • Cold Sweats
    		•  :    Yes   

    Heart Related
  • Previous history of heart attack / disease
    		•  :    Yes   
  • Angioplasty / stent procedure
    		•  :    Yes   
  • Bypass surgery
    		•  :    Yes   
  • Any other heart procedures
    		•  :    Yes   

    Stroke Related
  • Sudden numbness/weakness of the face, arms or legs/slurred speech
    		•  :    Yes   
  • Trouble walking, dizziness, loss of balance or coordination
    		•  :    Yes   
  • Sudden, severe headache with no known cause
    		•  :    Yes   

    Stroke Related
  • Any previous history of stroke?
    		•  :    Yes   
  • Any previous history of temporary weakness of face, arms or legs?
    		•  :    Yes   

    Cancer Related
  • Any significant loss of weight or appetite?
    		•  :    Yes   
  • Change in bowel habits/chronic diarrhoea
    		•  :    Yes   
  • Persistent cough or coughing blood
    		•  :    Yes   
  • Chronic fatigue
    		•  :    Yes   
  • Lump on any part of the body
    		•  :    Yes   

    Cancer Related
  • Any previous history of cancer?
    		•  :    Yes   
  • Have you undergone any treatment for cancer: surgery, radiotheraphy, chemotheray?
    		•  :    Yes   


** indicates required data field


   



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