Ask Dr. Stall Advice request Your name * Relationship * Patient Spouse Adult child Friend OtherOther Best phone * Email * Permission / Disclaimer " I give permission to Dr. Stall to review the information contained herein and render advice. I understand that information transmitted via this form and Dr. Stall's response via email is not HIPAA compliant i.e. may not be secure. " Consents * Yes, I agree to the Permissions / Disclaimer Consents * I am the patient, or a legal health care agent for the patient Main concerns * Care needs increased / overwhelming Frequent falling Gradual decline in health status New/worsening memory problem Possible medication side effect / too many medications Sudden decline in health status OtherOther Details of main concerns * Current primary care physician - name phone (e.g. Dr. John Smith 999-999-9999) Information available Current medications (list below) Test results (list below) Documents to upload OtherOther Current medications - name strength frequency (e.g. lisinopril 10mg once a day) Test results - date test result (e.g. 3/2/2022 TSH 6.2) Other information Documents to upload Drop a file here or click to upload Choose File Maximum file size: 67.11MB Captcha If you are human, leave this field blank. Δ
