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Patient Information
PATIENT INFORMATION
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Name
*
First
Last
Age
*
Gander
*
Male
Female
Email
Email
Confirm Email
Address
City
Pincode
Phone Number
*
How often do you exercise?
Daily
Weekly
Sometime
Never
Do You Smoke?
Daily
Weekly
Sometime
Never
Do You Consume Alcohol?
Daily
Weekly
Sometime
Never
Disease
a. Digestive Disorders
b. Diabetes Reversal
c. Arthritis & Joint Pain
d. Liver Diseases
e. Kidney Disorders
f. IBS & Piles
g. Eczema, Psoriasis & Skin Disorders
h. Headache & Migraine
i. Asthma & Respiratory disorder
j. Obesity-Related disorder
k. Infertility & PCOS
m. Auto-immune Disorders
n. Neurological Disorders
o. Sexual Disorders
p. Heart & Cardio-vascular Health
q. Mental health conditions
r. Eyes & Ear Diseases
Submit
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