Name:
Age:
Sex:
Address:
E-Mail:
Contact no.
General Sufferings:
Marital Status:
Education/Qualification:
State:
City:
Country:
Veg/Non-Veg:
Main Sufferings or Presenting Problem:
Sufferings Better By or When you feel Better:
Sufferings Worse By or When you feel Worse:
History of your Problem or Sufferings:
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