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Patients Record

First Name: Last Name:
Age: Weight:
Height: Marital Status:
Children: Blood Group:
Contact No: Mobile:
Email Id : Address:

Specify your main complaint / Symptom –

Please be specific and clear about your problem, it is advisable that you use your words and not medical terms. Describe if given symptoms made worse or better under any circumstances or the problem occurred after particular event in your life.

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Personal History:

Have you ever had the following (check all that apply)

Any Other please specify -

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