| * Required Fields |
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| | |
| Form No |
T-26 |
| Disease/Disorder : |
Tooth Ache
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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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300
