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Age : Yrs
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Present complaints with full history :
Nature of work: Whether it involves constant travelling, etc:
Any history of venereal disease, malaria, filaria or any other noticeable ailments:
State of Appetite, Digestion, Motion, Urine, Sleep:
Dietary habits :Veg or non veg and food timings.
Addiction to smoking, alcohol, etc:
Menstrual history, Gynaecological problems, if any:
Treatment done so far
Details of Investigation/Medical Reports
Any known Allergies :
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