Name |
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Address |
|
Phone |
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E-Mail |
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Fax |
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Age |
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Sex |
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Height |
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Weight |
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Marital status |
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Structure |
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Main
complaints with full history : |
|
Nature of work: Whether it involves constant traveling,
etc: |
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Any
cause known to you for the disease : |
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Any Hereditary factor : |
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Dietary
habits : |
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State
of Appetite, Digestion, Motion, Urine, Sleep, Menstruation: |
|
Addiction to
smoking, alcohol, etc: |
|
Details
of Investigation/Medical Reports |
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Other
Problems like hypertension, diabetes etc: |
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Any Previous & recent treatments :
|
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Other
information, if any: |
|