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Your Name    
Email ID     
User Name       
Height  Weight
Date of Birth Age
Marital status      
Explain your ailment, probable cause and symptoms:    
I have pain in my      
I have tension in my     
I have numbness in my     
I have skin problem on my    
Others, explain     
The following conditions or situation seem to make my ailment worse:    
I have been suffering from the Ailment (s) since (DD/MM/YY)    
I have undergone treatment as follows:    
a. Type of Medication    
b. Since (DD/MM/YY)      
Diabetic patient only, complete the below:    
My FBPS is     
My PPBS is      
My Blood Pressure    
Pregnant women only, complete the below:    
Month of Pregnancy    
Other remarks: