Medical History Form
Name
Age
Gender
Female
Male
Other
Date of Birth
Place / Delivery Address
Contact No.
Email-id
Time For Appointment
Want Consultation For your disease/problem
Previously taken any homeopathic medicine
Any allergies to drugs/ substances/ food
Any Reports /lab investigation
Are you on any medication and since when ?
Type of job / work you are doing
Any disease condition you are suffering from?
- select -
Diabetes
High blood pressure/ Hypertension
Pcos/pcod
Hypothyroidism
Hyperthyroidism
Asthma
Cardiac/ heart related complain
Skin disease/ allergie
Depression/ Anxiety
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