Medical Form

Medical History

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Information

Disease to be treated

Clinical History

Symptoms

If the answer is yes, please give an explanation in the box

If the answer is yes, please give an explanation in the box

If the answer is yes, please give an explanation in the box

If the answer is yes, please give an explanation in the box

If the answer is yes, please give an explanation in the box

If the answer is yes, please give an explanation in the box

If the answer is yes, please give an explanation in the box

If the answer is yes, please give an explanation in the box

If the answer is yes, please give an explanation in the box

If the answer is yes, please give an explanation in the box

If the answer is yes, please give an explanation in the box

If the answer is yes, please give an explanation in the box

If the answer is yes, please give an explanation in the box

If the answer is yes, please give an explanation in the box

If the answer is yes, please give an explanation in the box

Medications & Drugs

Operations

Which operations have you done so far

Other diseases

Do have other diseases you want to mention

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