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Case Record Form
( * ) Marked Fields are compulsory, Please enter valid information.
Name of the patient *:
Sex :
Male Female
Age * :
Present Complaints and duration:
1.
2.
3.
4.
* Previous major illness like Diabetes/ Hypertension/ Heart Disease/ Thyroid/ Asthma etc.
Previous major operations *
Allergies *
Any medication done for the above complaints
Your E-mail *