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First Name
Last Name
Gender		MaleFemale
Age
Full Name		Your Name (if different from patient)

About your medical condition

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MEDICAL CONDITION
Chief Complaints (with duration)
History of Present Illness		(Elaboration of chief complaints, with mention of general symptoms of disease, viz. history of loss of appetite, weight loss, history of bladder, or bowel abnormalities)
Treatment History		(With elaboration of details of previous treatment undertaken)
Family History		(Any significant family history of disease, related to current chief complaints)


Past History
Please select Yes or No wherever applicable; if Yes please provide more information in the adjacent text area, e.g., if suffering from hypertension, select Yes, and enter recently recorded blood pressure reading(e.g. 120/80 mm Hg)
Arthritides	YesNo
Asthma	YesNo
Diabetes Mellitus	YesNo
Dyspepsia	YesNo
Heart Disease	YesNo
Hypertension	YesNo
Tuberculosis	YesNo
Exposure to STD (sexually transmitted disease)	YesNo
Jaundice	YesNo
History of Trauma or Injury	YesNo
History of Surgery	YesNo
History of Gynaecological disease (for women)	YesNo
History of any other disease(s) not mentioned above:

Personal History

Non vegetarian?

YesNo

Do you take any Medicines?

YesNo
Drug(s) Details :

Do you have a history of smoking?

YesNo

Duration (in years)

Number of cigarette(s) or pack(s) per day

Do you have a history of consuming alcohol?

YesNo

Do you have history of chewing tobaco?

YesNo

Duration(in years)

Do you have a history of allergy(s)?

YesNo

Allergy(s) details :

Any other habits?


Attach soft copy(s) of other report(s) (if any)
Report 1	Report 2
Report 3	Report 4
Report 5	Report 6

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