* Required Fields |
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Form No |
T-23 |
Disease/Disorder : |
Colour Blindness
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* Name : |
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Gender : |
Male
Female
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Father
Husband
Guardian Name :
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Address : |
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City / Town : |
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State : |
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Country |
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E-mail : |
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* Contact No.: |
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Occupation: |
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DOB : |
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Age: |
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Weight : |
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Disease/Complaints/Pain/Problem : |
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Sleep : |
Disturbed
Sound
With Dreams
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Urine in day : |
( times ) |
Pain: |
before
during
after
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Urine in night : |
( times ) |
Pain: |
before
during
after
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Stool/Feces : |
Normal
Constipation
Hard
Loose
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Hunger : |
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Thirst : |
Normal
More
Less
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Taste : |
Sour
Sweet
Salty
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Menstrual Cycle : |
Clots
Scanty
Excess
Normal |
Attitude : |
Grumpy
Sprightly
Concerned
Depressed
Fearful
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Habit : |
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Past/Family History : |
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Pathology : |
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B.P. : |
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Clinical Examination/Investigation Report : |
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Other Report : |
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Diagnosist : |
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Treatment undergoing at present : |
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* Mode of Payment for Subscription : |
Payment Options
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I myself come for treatment on my own responsibility. Doctors & Institute are not responsible for any cause.
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* Enter code shown in image |
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