Qureshi University, Advanced courses, via cutting edge technology, News, Breaking News | Latest News And Media | Current News
admin@qureshiuniversity.com

Admissions | Accreditation | Booksellers | Catalog | Colleges | Contact Us | Continents/States/Districts | Contracts | Examinations | Forms | Grants | Hostels | Honorary Doctorate degree | Instructors | Lecture | Librarians | Membership | Professional Examinations | Programs | Recommendations | Research Grants | Researchers | Students login | Schools | Search | Seminar | Study Center/Centre | Thesis | Universities | Work counseling

Date:________________________________

Patient Name:________________________

Referred by:_________________________

Mailing Address:_____________________

Telephone:___________________________

Your Email Address:__________________

Date of Birth:_______________________

Gender: Male Female

Primary Care Physician Name, Address and Phone:__________________

Emergency Contact Name:______________

Relationship:________________________

Phone:_______________________________

Your Height:_________________________

Your Weight:_________________________

What seems to be the problem?



What is the reason for consultation?



Do you have any of these symptoms?
Check all that apply to you.
Gastrointestinal Symptoms:
    _____ Abdominal Pain
    _____ Nausea
    _____ Vomiting
    _____ Heartburn
    _____ Regurgitation
    _____ Difficulty Swallowing
    _____ Painful Swallowing
    _____ Change in Bowels
    _____ Diarrhea
    _____ Constipation
    _____ Bloody Stools
    _____ Black Stools
    _____ Abdominal Bloating
    _____ Excess Belching
    _____ Excess Flatus
    _____ Jaundice
    _____ Weight Loss
    _____ Poor Appetitie
Other Symptoms:
    _____ Chronic Cough
    _____ Shortness of Breath
    _____ Coughing up Blood
    _____ Chest Pain
    _____ Palpitations
    _____ Easy Bruising
    _____ Easy Bleeding
    _____ Blood in Urine
    _____ Painful Urination
    _____ Difficulty Urinating
    _____ Weakness Arm/Leg
    _____ Numbness Arm/Leg
    _____ Blurred Vision
    _____ Severe Headache
    _____ Fever/Chills
How did you arrive at qureshiuniversity.com today?

I used a search engine
I typed the address directly into the web browser
I linked from an email
I came from another site (Please specify)
Other (Please specify)

What is the primary goal of your visit to qureshiuniversity.com today? Please select the most appropriate answer from the list below.

Look for general treatment/therapeutic information
Research product-specific information
Look for conferences and events
Compare products/treatments
Look for clinical information
Contact Qureshi University
Other (Please specify)

Overall, how successful were we in enabling you to accomplish your primary goal during today's visit?

Extremely Successful
Successful
Unsuccessful
Extremely Unsuccessful

Which of the following best describes you?

I am a medical student
I am a Resident
I am a Fellow
I am a physician
I am a nurse
I am another type of medical professional
I am an administrator within a health care practice or hospital
I am a prospective patient
I am a member of the media
Other (Please specify)


These are basic questions.
There are many more.