Online Consultation Form

Patient Name

Email

Phone

Sex

Age

Date of Birth

Place of Birth

Place of residence/ Present Address

Patient Height

Patient Weight

Diagnosis

Occupation?

Complaints?

Medications (currently taking)?

Family History?

General Health

Sleep – duration and quality?

Appetite?

Bowel movement?

Urine output?

Habits?

Preferences

Skin texture

Woman – Menstrual history

Cycle/No of Days?

Flow/Associated problems ?

Other problems ?

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