» Sports injury counseling

Step 1 of 6 - Personal details

(Required)

First Name (Required) Last Name (Required)

Date of Birth(Required)

Month

Day

Year

Gender(Required)

Male

Female

Marital Status(Required)

Single

Married

Education(Required)

Diploma

Bachelor

Master

PhD

Height (cm)(Required)

Weight (kg)(Required)

Job(Required)

Blood Group

Phone Number(Required)

Email (Results are sent via email)(Required)

Payment (30$ )

Please email transfer to: Dr.Bahrami@gmail.com or Paypal to: Dr.Bahraminejad@yahoo.com

The full name of the payer:(Required)

Date of Payment(Required)

Month

Day

Year

Payment Receipt(Required)

Max. file size: 256 MB.

Please Briefly explain the reason for requesting counseling(Required)

Please describe your chief complaint at this time(Required)

How many days ago did your symptom begin?(Required)

Is your condition ongoing?(Required)

Yes

During which times of the day is it more severe?(Required)

Do you have limited joint mobility?(Required)

Yes

Which joint is affected & how limited is it?(Required)

What makes the pain better or worse?(Required)

Do you have chest pain, palpitations or shortness of breath?(Required)

Yes

Describe how it started & worsened?(Required)

Do you experience dizziness and headaches?(Required)

Yes

Describe how it started & worsened?(Required)

Do you have digestive issues?(Required)

Yes

Describe how it started & worsened?(Required)

Have you ever had a medical condition?(Required)

Yes

Specify the condition and it is duration(Required)

Have you ever been hospitalized?(Required)

Yes

Specify the reason for hospitalization & its duration(Required)

Have you had a muscle, bone or joint injury?

Yes

Describe the injury location, timing & progression(Required)

Do you take any medications?(Required)

Yes

Specify the medication and dosage(Required)

Do you take any supplements?(Required)

Yes

Specify the supplement & dosage(Required)

Do you use tobacco, alcohol or drugs?(Required)

Yes

Specify the type and amount(Required)

Do you have any allergies?(Required)

Yes

Describe the allergy & the symptoms(Required)

Do any of your first degree relatives have a medical condition?(Required)

Yes

Fully describe the condition(Required)

Have any first degree relative died due to a medical condition?(Required)

Yes

Fully describe the cause of the condition(Required)

Is there a family history of high blood pressure, diabetes or high cholesterol(Required)

Yes

Specify the type & severity(Required)

Blood Pressure (Minimum)

Blood Pressure (Maximum)

Pulses Rate (per min)

Respiratory Rate (per min)

Body Temperature

If you have any additional information not mentioned above, please describe it here

Which language would you like to received the consultation outcome in?(Required)

Persian

English

Send X-ray and Lab test

Max. file size: 256 MB.

(Required)

I confirm that the above information is correct (required)