Data Privacy

‍_{In compliance with the Data Privacy Act of 2012, Makati Life Medical Center ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared with your consent. By completing and submitting this form, you agree to the processing of your data in accordance with Makati Life Medical Center Patient Privacy Policy. To secure your slot, kindly fill out this form.}

Takes about 5 minutes

Let's start with your basic information.

First Name

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Middle Name

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Last Name

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Age

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Email Address

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Mobile Number

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WELLNESS SCREENING QUESTIONS

Question 1 — Nutrition & Hydration

I eat balanced meals regularly and stay adequately hydrated.

I occasionally skip meals or rely heavily on coffee to get through the day.

I frequently experience fatigue or digestive discomfort, or struggle to maintain regular meals.

WELLNESS SCREENING QUESTIONS

Question 2 — Fitness & Mobility

I exercise regularly and generally feel energetic.

I occasionally skip meals or rely heavily on coffee to get through the day.

I frequently experience fatigue or digestive discomfort, or struggle to maintain regular meals.

WELLNESS SCREENING QUESTIONS

Question 3 — Stress & Sleep

I usually get enough restful sleep and manage stress well.

I sometimes experience insufficient sleep, stress, or difficulty concentrating.

I frequently wake up exhausted or experience significant stress that affects my daily activities.

WELLNESS SCREENING QUESTIONS

Question 4 — Preventive Health Check

Within the past 12 months.

More than 12 months ago but within the past 2 years.

More than 2 years ago, or I cannot remember.

Your Information Summary.

Your Details

First Name

Last Name

Middle Name

Date of Birth

Contact email

Phone

Provider

HMO Account Number

HMO Card Number

Medical Information

Type of LOA

Date of Availment

Preferred or Existing Doctor

Specialization

Chief Complaint

Diagnosis

Request Sent!

Our team will reach out to you within 24 hours!

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