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Online Consultation


Case Record Sheet for On-line Consultation
Fields marked with * are mandatory
Name : *
Age : *
Address : *
Education :
Weight   Kg*
Are u a :
Vegetarian Non-Vegetarian
Chief Complaint : *
Family History :
USG/MRI/Scan Reports :
 
Sex : Male     Female  
Profession :
E-mail : *
Marital Status :
Married Unmarried
Single Divorcee
Blood Pressure :
Height :
Inches
Dependence on :
Alcohol Drugs
Smoking Coffee/Tea
Personal History :
Laboratory Investigation Reports (if any) :
Other information which you think might be helpful :
Image Verification Code
*(Please enter key in the above code as it appears in the box.
All letters are in capital.)