| 1 |
Name |
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| 2 |
E-mail |
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| 3 |
Address |
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| 4 |
Sex |
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| 5 |
Age |
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| 6 |
Weight |
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| 7 |
Height |
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| 8 |
Present Complaints |
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| 9 |
How the complaints started? |
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| 10 |
Any peculiar symptoms? |
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| 11 |
Is it occurred previously? |
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| 12 |
Disease history in your family? |
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| 13 |
Whether consulted anywhere earlier? |
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| 14 |
Are you feeling chilliness/Hot flushes? |
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| 15 |
How is your appetite? Any desire for salt/sour/spices/sweets/fish/meat/egg. Etc. |
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| 16 |
Favourite food items |
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| 17 |
The food that aggravates your existing complaints |
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| 18 |
Please describe your mental attitude/ past mental insults/ unsolved grief etc. |
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| 19 |
Any history of suppressed eruptions/ skin complaints |
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