This form is a screening tool to help your doctor identify red flags for any conditions needing attention.

The results of this form are not meant for use by the patient.

The results of the form are dependent upon the entries made by the patient. The results of the form do not diagnose any disease and do not prescribe any solutions. They may help the doctor to take appropriate action as the doctor deems fit.

Kindly show the results to your doctor, so they may advise you appropriately.