Generate Prescription Subject *Patient's Name *Your Email ID *Your Email by which we will get back to you.Phone Number *Address Please enter your addressPresent Illness (How did it start , duration etc.) *Upload existing prescription History of past illness (if any) Family History (Does any of your blood relation suffer from similar illness) Family HistoryDrug History ( Do you use any drug, alcohol or tobacco habitually ) *Drug HistoryAge *Sex *MaleFemaleMarital Status MarriedUnmarriedHeart Rate Blood Pressure (in mmHg) *Height (in feet and inches) Weight (in kilograms) *Blood sugar (in gm/dl) Profession Rate your sleep on the scall 1 to 5 Rate your sleep on the scall 1 to 5 12345Bowel habit Bowel habitDryHardPasteProperSleep Habit Sleep HabitdisturbeddeepdelayedDo you dream Do you dreamlots of dreamno dreammoderateFood habits Food habits VegetarianNon-vegetarianDo you have any experience of using cannabis in any form? Are you allergic to any drug, antibiotic or any other supplement? *Please enter the details of your request. A member of our support staff will respond as soon as possible.Current Medication, If any Submit RequestReset Request Check your Existing Request Powered by WSDesk Confidentiality Notice: All information in this personal Health Care Record is strictly confidential, that is legally privileged.