Please enable JavaScript in your browser to complete this form.Dateنام مریض ، مریضہ | Paitent's Name *FirstLastعمر | Age *جنس | Gender *مرد | Maleعورت | Femaleمخنس | Shemaleبچوں کی تعداد | No of Children *ازدواجی حیثیت | Marital Status *شادی شدہ | Marriedغیر شادی شدہ | Un-marriedطلاق یافتہ | Divorcedپیشہ | Professionرابطہ نمبر | Contact No *Submit Name Email Address Message 2 + 13 = Submit Patient Information Form Patient Name Gender MaleFemaleShe-male Marital Status MarriedUnmarriedDivorced No of Kids Profession Please explain your problems, also indicate when did it start, also give your opinion as to what could be its reason?/b> Have you ever had a major disease like Typhoid, pneumonia etc... Which medicines have you taken for those diseases, name it Please indicate diseases prevailing in your father and his family members Please indicate diseases prevailing in your Mother and her family members Have you experience any major diseases in your childhood? Name any diseases in your brothers and sisters. Have you had any accidents? Write some words about your personality If you have any type of fear,(fear of height, fear of water, fear of death) please indicate? Do you constantly think about anything? Which weather condition is unbearable for you? Which part of the day do you feel better or worse? What food you have craving for? Please define your thirst preferences? Please write any worth mentioning symptoms from head to toe. Phone Number Address City State / Province / Region Email Preferred Contact Method EmailPhone Drop-down menu Option 1Option 2Option 3 Checkboxes Option 1Option 2Option 3 Lorem ipsum dolor sit amet, consectetur adipiscing elit. Vestibulum tempus pharetra vehicula. Aliquam pellentesque mi non scelerisque placerat.
