Gender: MaleFemale Marital Status: MarriedSingle Are you a Vegetarian: YesNO Dependence on: AlcoholDrugsSmokingCoffee/TeaOther Substances/Medication Any Past History: Hypertension (high B.P.)DiabetesAllergySurgeryOthers Planning for Pregnancy in next 6 Months: YesNo Duration of the complaint: Functional history: AppetiteAcidityGasMotionUrination – day/nightSleep – day/nightDiet - veg/non vegLifestyle – daily general routineOthers Blood group: Upto 1MB and in JPG/JPEG/PNG/PDF formats and up to 5 files only Photo:
