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.

Your answers are retained as you move between sections.

Current sectionComplaints and goals1 / 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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Current medications

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3. Nutrition and lifestyle

Bowel function

Record the usual bowel movement frequency and stool characteristics, even if there are no other gastrointestinal complaints.

Bowel movement frequency Stool characteristics

Briefly describe your usual dietDaily water intake SmokingAlcohol Physical activitySleep

Stress level from 0 to 10

5

4. Gastrointestinal complaints

Bowel function

Record the usual bowel movement frequency and stool characteristics, even if there are no other gastrointestinal complaints.

Bowel movement frequency Stool characteristics

Do you have 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

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Pain location

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Heaviness after meals

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Bloating

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Flatulence

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Heartburn

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Sour or bitter belching

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Nausea

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Vomiting

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Unpleasant taste

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Bad breath

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Reduced appetite

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Increased appetite

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Early satiety

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Constipation

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Diarrhea

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Alternating constipation and diarrhea

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Stool color change

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Stool form or consistency change

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Mucus in stool

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Blood in stool

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Incomplete evacuation

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Stool frequency change

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Food intolerance

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Worsening after specific foods

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Unexplained weight loss

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Weight gain

Severity 0–10 Onset date or periodDuration FrequencyRelation to meals Aggravating factorsRelieving factorsNote

Other complaints

Severity 0–10 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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Additional options

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.