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Phone :
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Name :
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Email :
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Date of Birth :
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Marital Status :
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History :
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Psychiatric
illness
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Hypertension :
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Tuberculosis :
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Depression :
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Surgeries :
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Injuries :
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Hospitalisation :
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Smoking :
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Drinking :
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Diabetes :
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Chief complaint(s) and other concerns (for all patients)
Please list what you are experiencing in the order of severity below and describe in your own words the sequence of events starting with the time when you were alright.
Describe your Symptoms. When did they start? Where? What is affected? When does it happen? Describe the quality? throbbing/spasms? How frequently did you have the problem? Symptoms
increased due to? Symptoms decreased due to? Associated symptoms? Shifting of symptoms? Any loss of function?
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Select one or more Questions that are applicable using "Ctrl" key
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Please mention allergies
and reaction to drugs, if any.
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Are you taking any
medication currently?
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Examination option : (Disclaimer: It is strongly recommended that you get examined by a doctor)
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City / Location
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Consultation /Referral Fee ( US $ 3.99 or Ind Rs 199)
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Cheque/Draft/ Bank transfer/Plan code/ other Preferred payment method
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I agree to the terms and conditions
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