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Your Name
Email ID
User Name
City
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: