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Name
Nationality
Date on birth
Height (cm)
Weight (kg)
Sex
Male
Female
Profession
Occupation
E-mail address
Telephone #
Fax #
Marital status
Married
Unmarried
Present complaint with duration (most serious problem first)
Symptoms with duration
1.
2.
3.
4.
If already diagnosed - details
Investigated details (if any)
Investigation done – details of available
Diagnosis
Drugs prescribed with dose and how long taking them
Diabetes Mellitus
High BP
Cancer
Arthritis
Asthma
Allergy
Sleep
Appetite
Bowel Habits
Urination
Addicted to Tobacco / Alcohol / Drugs
Present diet - regime