Questionnaire Dr

About you

Personal Information

Takes about 12–15 minutes. Your answers save automatically on this device, so you can pause and pick up later.

Every question on this page is required. Fields marked * must be completed before you can continue.

Before we begin — how we handle your data

The information collected in this form is used strictly by Dr Sharan's Clinic. Under the Malaysian Personal Data Protection Act (PDPA), this information is classified as sensitive personal data, and we therefore require your consent to use it in providing your care.

I understand and consent to Dr. Sharan's Clinic collecting and using my health information as described above*

Full Name*

Gender*

This tailors the rest of the form. The women's health section only appears for female patients.

I/C or Passport No.*

Malaysian I/C? We'll fill in your birth date automatically.

Birth Date*

Your age is calculated from this date.

I don't know my exact birth date

Age (in years)*

Home Address*

Postcode*

City*

Country*

Mobile No.*

Home No. optional

Work No. optional

Email Address*

How often do you check email?*

Your measurements

Height (cm)*

Current Weight (kg)*

Blood Pressure (mmHg)* last checked

Pulse (per min)* last checked

I don't know my last blood pressure or pulse reading — the clinic can take it at my visit

Goal Weight (kg)*

Lowest Adult Weight (kg)*

Highest Weight (kg)*

Referred By*

Main Reason for Visit*

In case we need it

Emergency Contact & Social Information

Name*

Relation*

Phone No.*

Email Address optional

Relationship Status*

Children & ages optional

Pets optional

Occupation*

Work hrs/week*

Your history

Medical History

Tick everything that applies to you. If nothing applies, tick None of these apply to me so we know the question wasn't missed.

Additional Information optional

Family Medical History*

Tell us about your parents at minimum. Siblings are optional.

I don't know my family medical history (e.g. adopted, no contact)

Care & medications

Surgeries, Allergies & Medications

Each list below must be answered. If a list doesn't apply to you, tick its None box.

Surgeries & Hospitalisations*

I have never had surgery or been hospitalised

Medication Allergies*

No known medication allergies

Food Allergies*

No known food allergies

Prescription Medications*

I don't take any prescription medication

Supplements & Over-the-Counter*

I don't take any supplements or over-the-counter medicine

Screening & wellbeing

Screening & Personal History

For each screening, give the date of your last one and its result — or select Never if you haven't had it done. Only screenings relevant to you are shown.

Result: Norm = Normal, Abn = Abnormal.

Are you under another physician's care?*

What type of physician?*

Stress level (1–10)*

Not set

1 – Low stress10 – Extreme stress

Drag the slider (or tap it and use your arrow keys) to set your level.

What is your main source of stress?*

Required when your stress level is 4 or above.

Do you have an autoimmune disorder?*

Which one?*

Daily life

Sleep, Fitness & Habits

A typical night's sleep*

Hours of sleep per night*

Do you use sleep aids?*

Fall asleep easily?*

Wake up often?*

Do you dream?*

Snore?*

Feel rested on waking?*

Tired in the afternoons?*

Fitness lifestyle*

Activity Level*

Describe your exercise routine*

How long have you kept this routine?*

Habits that affect your health*

Do you drink alcohol?*

What kind?*

How often?*

Do you use tobacco or vape?*

Packs per day or week?*

Year quit if you have quit

Do you use recreational drugs?*

What kind?*

How often?*

How you feel

Hormone Symptoms

Tick every symptom you experience. If you have none of them, tick None of these apply to me.*

Female patients

Women's health

PCOS Evaluation

You're seeing this section because you selected Female. All questions here are required.

I no longer menstruate (menopause, hysterectomy, or other reason)

Last Menstrual Period*

Cycle length*

Period symptoms*

Tick all that apply, or tick "None" if your periods are trouble-free.

Age of First Period*

Pregnancies*

Live Births*

Miscarriages*

Difficulty Conceiving?*

Do you still have your ovaries?*

Have you had a hysterectomy?*

Have you been diagnosed with PCOS?*

PCOS-related conditions*

Private & confidential

Sexual Health

These answers help assess hormone balance. They are seen only by Dr. Sharan.

Are you sexually active?*

Are you satisfied with your sexual activity?*

Libido (1–5)*

Not set

1 – Very low5 – Very high

Drag the slider (or tap it and use your arrow keys) to set your level.

Issues you would like to address*

Food & drink

Nutrition Evaluation

Describe your diet*

Meals per day*

Snacks per day*

Weekly Vegetable Intake*

Roughly what share of your weekly food is vegetables?

Weekly Fruit Intake*

Water per day*

Food aversions optional

Food cravings optional

Drinks you have regularly*

Eating habits*

Please answer every row.

Almost done

Additional Information & Consent

How motivated are you to make changes?*

Anything else we should know? optional

Will you discuss treatment with your partner?*

Consent – BHRT*

I have read and agree to the consent above*

Patient Full Name (as signature)*

Type it exactly as you entered it in Step 1.

Date*

Thank You!

Your health questionnaire has been submitted successfully. Dr. Sharan's Clinic will review your information before your appointment. If you have any questions, please contact the clinic directly.

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