Online Consultation Step 1 of 3 33% Hospital Number, if anyName of the patient*AddressEmail Address* Phone*Fax Date of Birth AgeGenderMaleFemaleHeightWeightStructureObeseMediumLeanJob DetailsNature of workPresent complaints with duration*Full History of present complaintsSymptoms increased during the time 6 AM to 10 AM 6 PM to 10 PM 10 AM to 2 PM 10 PM to 2 AM 2 PM to 6 PM 2 AM to 6 AM Details of treatments doneFamily History:Current MedicationAllergiesHistory of previous illnesses (Option)Past Medical History State Of DigestionAppetiteNormalLessMoreBowel HabitsRegularIrregularUrine QuantityAdequateLessMoreSleepAdequateLessMoreMenstruationCycleRegularIrregularFlowNormalLessMoreMarital StatusMarriedUnmarriedAddiction if anyAlcoholSmokingTobacco chewingDelivery: Problems if anyEarly MorningEarly Morning MenuEarly Morning TimingsBreak FastBreak Fast MenuBreak Fast TimingsMid MorningMid Morning MenuMid Morning TimingsLunchLunch MenuLunch TimingsNightOthers please specify: (favorite foods)Please Enter Captcha This iframe contains the logic required to handle Ajax powered Gravity Forms. Orthopedic aliments Skin Diseases Gynecological Diseases Neurological Diseases Psychiatric Diseases Gastroenterological Diseases
