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Name
*
First
Middle
Last
Details
Birth Date
*
Any ID - AADHAR / DL/ PP / PAN
Height
*
In Centimeters
Weight
*
In Kilogram
Email
*
Phone
*
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
--- Select country ---
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Country
Next
Chief Complaints
*
Past History of Any Disease
*
Measles
Mumps
Chickenpox
Chicken Gunia
Maleria
Jaundice
Typhoid
Renal Stone
Gall Stone
Heart-Attack
Piles
Other
Any Other Past Disease History:
Upload Investigation if Any
Drag & Drop Files,
Choose Files to Upload
Next
Family History
Father
*
Short stature
High Blood pressure
Diabetes
Heart-attack
Cancer
Skin Disease
Obesity
Not Any of Above
Paternal Grand Father
*
Short stature
High Blood pressure
Diabetes
Heart-attack
Cancer
Skin Disease
Obesity
Not Any of Above
Paternal Grand Mother
*
Short stature
High Blood pressure
Diabetes
Heart-attack
Cancer
Skin Disease
Obesity
Not Any of Above
Mother
*
Short stature
High Blood pressure
Diabetes
Heart-attack
Cancer
Skin Disease
Obesity
Not Any of Above
Maternal Grand Father
*
Short stature
High Blood pressure
Diabetes
Heart-attack
Cancer
Skin Disease
Obesity
Not Any of Above
Maternal Grand Mother
*
Short stature
High Blood pressure
Diabetes
Heart-attack
Cancer
Skin Disease
Obesity
Not Any of Above
Next
Developmental History in case of Children
*
Milestone Normal
Late learning to Walk
Late learning to Talk
Obstetric and Gynecological History For Females
Regular
Irregular
Profuse with Clots
Absent
Leucorrhoea / White Discharge
YES
NO
Details of Leucorrhoea / White Discharge
White
Yellowish
Greenish
Offensive Smell
Next
Generalities
Addiction
Alcohol
Tobacco
Smoking
Tea
Coffee
Drugs
Water Thirst
*
Normal
Absent
At a Time Small quantity at a small interval
At a Time Large quantity Large Interval.
Like & Don't Like
Desire / Likes
*
Sweet
Spice
Sore
Salty
Fruits
Green Vegetable
Bakery Products
Eggs
Fish
Chicken
Meat
Aversion / Don’t like
*
Sweet
Spice
Sore
Salty
Fruits
Green Vegetable
Bakery Products
Eggs
Fish
Chicken
Meat
Appetite
*
Normal
Increase
Absent
Next
Bowel Habit
Stool
*
Regular
Insufficient
Constipation
Stool with Bleeding
Urine
*
Normal
Increase
Absent
Involuntary Urination
Sleep
*
Sound
Increase
Insomnia
Disturbed
Perspiration
*
Normal
Increase
Offensive
Relation with Heat and Cold
*
Tolerate Cold
Tolerate Heat
Can Tolerate Both
Can not Tolerate Both
Memory Status
*
Poor
Weak
Average
Sharp
Anxiety about
Health
Money
Future
Family
Children
Job
Other
Mentioned here Other Anxiety about -
Likes / Dislikes
Music
Company with friends
Other
/ Height /
Mentioned here your other Likes / Dislikes
Next
Your Nature (Evaluate Your Self)
*
Ambitious
History of Disappointment
History of Grief
Perfectionist
Time Punctual
Want Clean Everything
Can Not Tolerate Insult
Can Not Tolerate Injustice
Any Specific Mental Symptoms
Do you have fear of ?
*
Darkness
Ghost
Height
Dog
Lizard
Cat
Rat
Insets
Snake
Teacher
Other
Checkboxes
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