MEDICAL REVIEW OF MEDICINES, SUPPLEMENTS AND MEDICAL CONDITIONS
Dr Evangelos Panagiotakos

Complete on your own device. Send to the doctor using the MioDottore app chat, following the practice's privacy information. Do not send to Tizy's commercial chat or site assistant.

Full name:
Date of birth:
Booking date:
Preferred language:
Date completed:
Usual treating doctor, if relevant:

YOUR QUESTION FOR THE DOCTOR
Which medicine, supplement or combination do you want assessed? What is your concern?

COMPLETE, UP-TO-DATE MEDICAL HISTORY
Current and previous conditions (diagnoses and dates):
Operations, admissions and relevant history:
Allergies, intolerances and known adverse reactions:
Known kidney or liver problems:
Pregnancy/breastfeeding, if relevant:
Other relevant information:

ALL MEDICINES — repeat for each
Brand name, active ingredient and formulation:
Strength of the product:
Actual dose:
Timing, frequency and route:
Continuous or as-needed use:
Reason for use, start date and planned duration:
Prescriber, if known:
Include over-the-counter medicines, creams, drops and other treatments.

ALL SUPPLEMENTS AND OTHER PRODUCTS — repeat for each
Exact name and brand:
Already taking or considering:
Ingredients and amounts per dose (attach label):
Actual or planned dose and frequency:
Start date, duration and reason for use:
Include herbs, teas and products not already listed.

EXISTING RELEVANT REPORTS
Cardiology: report title/date, or not available/not performed.
Neurology: report title/date, or not available/not performed.
Internal medicine: report title/date, or not available/not performed.
Other specialists, discharge summaries, laboratory or imaging results:

ATTACHMENTS
File names with dates and descriptions:

You do not need all three specialist assessments. The doctor decides whether additional information is needed. Do not stop or change medicines to complete this form.