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Name  

:

  

 

 

  First Name                Last Name

Postal Address  

:

Age  

:

Sex  

:

Male Female

Addiction  

:

 

 

Other:

Marital status  

:

E-mail Address  

:

Phone No.  

:

Type of Work  

:

Mental Status  

:

 

 

Other:

Sleep  

:

Normal Disturbed Insomnia

Eating Habits  

:

Intake of water (in glass)  

:

Bowel habit  

:

Type of motion  

:

 

 

Other:

Color of Urine  

:

Normal Red Yellow

Menstruation  

:

                (optional)

 

 

Other:    

Present Complaint (optional)

:

 

 
 

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