Patient details

Patient details

Patient ID settings

Patient Name * settings

Date of Birth settings

Gender * settings

Male

Female

Marital Status settings

Single

Married

Divorced

Widowed

Patient Email * settings

Phone Number * settings

Address * settings

Social Security Number settings

Emergency contact

Emergency Contact Name * settings

Emergency Contact Phone settings

Emergency Contact Email settings

Relationship settings

What is the primary health concern? Tell about your symptoms in detail. * settings

ANSWER ALL THREE QUESTIONS. DON'T SKIP ANY ONE.

1- From how long you suffering ? Duration.

2- Does patient feel marked body weakness? General body weakness? (Yes/No)

3- How and when pain/symptoms increase ? (Select one option only)

Morning, evening, after eating, after coition/sex/masturbating, from cold weather or food, from warmth weather or food, from mental exertion/over work, from pressure or pressing, by motion/moving.

Carefully select one option only.

What are your goals that bring you to the clinic?

* settings

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Patient details

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