MCR-PQ-01 · v1.6.0

Pre-Consultation Medical Questionnaire

Complete the questionnaire and upload available laboratory results, reports and prescriptions. This information helps the doctor prepare for the consultation.

Demo mode: This is a demonstration preview of the questionnaire. Data is not saved to the database and is for review only.

Fields marked * are required.

Step1 / 6

2. Medical history

Chronic conditions and diagnoses

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Previous operations

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Allergies and adverse reactions

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Relevant family history

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Current medications

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Vitamins and supplements

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3. Nutrition and lifestyle

Briefly describe your usual dietDaily water intake SmokingAlcohol Physical activitySleep

Stress level from 0 to 10

5

4. Gastrointestinal complaints

YesNo

General GI assessment

When did the symptoms first appear?Relationship to food Foods that worsen symptomsFoods that improve symptoms Previously diagnosed GI conditions

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Previous GI diseases

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GI operations

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Gastroscopy results

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Colonoscopy results

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Ultrasound results

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Laboratory results

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History of Helicobacter pylori Helicobacter pylori treatment

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Current therapy

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Previously used medicines

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Previous supplements and herbal products

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Drug intolerance

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Meals per day Usual last meal timeOther important information

Select current symptoms

Select a symptom to open additional fields.

Abdominal pain or discomfort

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Pain location

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Heaviness after meals

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Bloating

Severity 0–10

7

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Flatulence

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Heartburn

Severity 0–10

4

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Sour or bitter belching

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Nausea

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Vomiting

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Unpleasant taste

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Bad breath

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Reduced appetite

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Increased appetite

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Early satiety

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Constipation

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Diarrhea

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Alternating constipation and diarrhea

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Stool color change

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Stool form or consistency change

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Mucus in stool

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Blood in stool

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Incomplete evacuation

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Stool frequency change

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Food intolerance

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Worsening after specific foods

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Unexplained weight loss

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Weight gain

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Other complaints

Severity 0–10

5

Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Red flags

An alarm symptom was marked. Additional medical evaluation is required. The system does not generate a self-treatment conclusion.

5. Documents and additional information

Previous tests and investigations

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What else should the doctor know?

Document typeUpload documents

PDF, JPG, PNG or WEBP; up to 10 MB each, maximum 10 files.

6. Consent and submission

I consent to the processing of the personal and medical data provided for arranging the consultation. * I allow the team to contact me using the details provided. * I understand that functional hemoscanning is not an independent medical diagnosis and does not replace laboratory testing or a physician consultation. *

This platform does not diagnose or replace in-person medical care. Seek medical or emergency help if your condition suddenly worsens.