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Name
Email
Age
Sex Male Female
Address
Profession
Marital Status MarriedUnmarried
Single   Divorcee  
Education
Blood Pressure
Weight   Kilograms
Height   Feet    Inches
Are You Vegetarian Non-Vegetarian
You are Dependent on Alcohol  Smoking     
Drugs     Coffee/Tea 
Main Complaint
Personal History
Family History
USG/MRI/Scan Reports
Laboratory Investigation Reports
(if any)
Other information,might be helpful