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Does your complaints aggravate during (please tick)

Present complaint with duration (most serious problem first)
Symptoms with duration

Do you have any of the following

Disease   Duration Current Medication
Diabetes Mellitus
Hypertension
Heart disease
Elevated Cholesterol Level
Bronchial Asthma
Skin infection
Thyroid Problem
Hair falling
Diabetes Mellitus
Enlarged Prostate
Cancer
Disk problems
Arthritis
Stroke
Sleep disorder
Stress
Mood change
Addiction to tobacco/alcohol
Osteopenia/Osteoporosis
Others

Most recent tests done

For Females (Menstrual Cycle)