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    Dependence on: AlcoholDrugsSmokingCoffee/TeaOther Substances/Medication

    Any Past History: Hypertension (high B.P.)DiabetesAllergySurgeryOthers

    Planning for Pregnancy in next 6 Months:

    Duration of the complaint:

    Functional history: AppetiteAcidityGasMotionUrination – day/nightSleep – day/nightDiet - veg/non vegLifestyle – daily general routineOthers

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