QUEEN MARY HOLISTIC CENTER, Medical Plaza, Ortigas Center, San Miguel Ave., Pasig City, Philippines 1605
WE CAN HELP YOU . Just fill up this form completely and submit to us to process your data and schedule of your appointment. Please check if you have or have had any of the following: AIDS/HIV Alcoholism Allergy shots Anemia Anorexia Appendicitis Arthritis Asthma Bleeding Disorder Breast Lumps Bronchitis Bulima Cancer Cataracts Chemical dependency Chicken pox Depression Diabetes Emphysema Epilepsy Fractures Glaucoma Goiter Gout Heart disease Hepatitis Hernia Herniated disc Herpes High cholesterol Kidney disease Liver disease Measles Migraine headaches Miscarriages Mononucleosis Multiple sclerosis Osteoporosis Pacemaker Parkinson’s disease Pnemonia Polio Prostate problems Psychiatric care Rheumatoid arthritis Rheumatoid fever Scarlet fever Stroke Thyroid problems Tonsilitis Tuberculosis Tumor growth Ulcers Other_________________ Family history: please indicate if any members have had any of the following medical problems and is so who: Diabetes Hypertension Stroke Alcohol problems Mental/emotional problems Heart disease Hepatitis/liver disease Cancer Congenital problems Other___________________