General Patients

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Form for General Patients













MaleFemale


Alcohol UsageTobacco Usage

VegNon-Veg

General Information


Are you carving about particular kind of food (eg. Sweet, Sour, Salty, Spicy etc.)Are you sensitive or allergic to any kind of food





Elimination




Sleep



Nature



Past history


Family history


For Female Patients only..



RegularIrregular





(eg. heaviness / pain in breast / change in mind, headache, backache, pain in legs, changes, in appetite, thirst or bowel, dreams etc.)



No. of children:



NormalCessarionAny abortion