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Your Name:
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Your Question:*

I am asking a question about:*

About the patient
Date of Birth:*
Gender:*	Male Female
Weight:*
Height:*
Occupation:*

About the current problem
When did the problem start?
Is any pain felt? Yes No	Where
What makes the problem worse?
Are there any associated symptoms?

Past history
Has there been any illness in the past?Yes No	Please give details
Any allergies?Yes No	Please give details

Drug history
Any medication?	Yes No
Name of medicine(s), dosage and since when
Any allergy to medicines?Yes No	Please give details

Family history
Any family members had a similar illness?Yes No	Please give details