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Online Consultation

Name of the patient:*
Gender:* Male Female
Address:*
E-mail:*
Tel:*
Fax:
Age:*  
Main Health Problem & Since how
long you have this Problem?:*
Any other associated health Problems & Since how long you have this problem *
What is your profession
Are you allergic to any thing
How is your sleep
How is your hunger / digestion and bowel movements
Are you taking any medicines for any disorders
Brief about your body structure and mental performance
History of any chronic illness / Accidents / Surgery /Continuous use of medicine
Any habits / addiction
Any other information you wish to provide
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