| Personal information |
| Regd No |
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| Name |
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| Age |
Years |
| Gender |
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| Address |
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| City |
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| State |
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| Postal code |
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| Country |
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| Phone no |
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| Email |
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| Height |
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| Weight |
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| Occupation |
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| Disease Realated Infomation |
|
| Name of your Disease |
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| Chief Complaint About Your Problems |
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| Signs or Symptoms |
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| How long you are suffering from |
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| Dietary Details |
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| Your Food and life style habits |
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| Any food or weather Increase or decrease your problem |
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| Any other Disease |
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| Presently On Medicines |
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| Are you Suffering from any other health problem (Diabetic , Hypertension , Heart Problem , Any Other Disease etc) |
|
| About your Digestive System |
| Appetite |
|
| Bowel Movements ( Like Acidity , Constipation , Normal , Other Disease Etc.) |
|
| Urinary System |
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| Sleep |
|
| Mental Condition |
|
| Treatment History |
| Your Previous Medical History |
|
| Results of that treatment |
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| How do you find us |
|
| Anything more you want to tell about your health problem |
|
| Upload Image |
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