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Complementary Specialist Form
Complementary Therapist

Form for consultation with Complementary Therapist

The form covers many areas; however there are only very few questions that are mandatory

Complementary Specialist
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Question*
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Basic Details

Name*
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E-Mail*
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City
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Country
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Contact Number
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Patient's personal details

Age*
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Sex*
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Occupation*
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Height*
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Weight*
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Patient's medical condition

When did it started*
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Details of medication taken*
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Any other associated complain with it*
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If Yes, Describe About It
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Past history

Have you been suffered from same or other illness*
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Yes, please describe about it
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Any other major illness or surgery *
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Yes, please provide information
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Description about medicine and dosages
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Any Allergy to Medicine / Food / Other*
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Family history

Any family members had similar illness
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Yes, please give details
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Upload Your Latest Report
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