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Name  
Address
Phone
Sex
Age
E -mail 
Occupation
Chief Complaints
Associated Complaints
Family History
Past & Treatment History Appetite       Good / Bad          
  Thirst     
                   Glases / Day
  Motion      Regular / Irregular
  Urine      
  Sleep      
 
                     Hours /Day
  Menses   
  Mind        
                                        
 
     
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