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appointment Form
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Name of the patient :
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Gender :
Male
Female
Age :
Date of Birth :
Full Address :
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Phone :
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Email :
Occupation :
Height :
Weight :
Kilos
Pounds
Present complaint with history :
Duration of complaint :
Years
Months
Days
Type of medications used/using :
Past problems and medications used :
Detail existence of problems like diabetes,
hypertension, cardiac problems :
Details of any laboratory investigations :
Appetite :
Normal
Less
High
Sleep :
Normal
Less
High
Bowel/stool :
Normal
Constipation
Loose
Bladder/urination :
Normal
Decreased
Increased
Addictions :
None
For Ladies
Menstrual history :
Pain
Any other dis-comfort
Bleeding :
Moderate
Low
Excess
Addictions :
Regular
Irregular