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Personal Information Sex:   Age:   Weight:
Additional Comments :
FOOD HABIT Spicy:                          Normal:               
Vegetarian:                Non-vegetarian:   
Like Sweet Food:        Salty Food:          
TEMPERAMEN Cool:                         Violent:                
MENSURATION Normal:                     Not Normal:        
If Not Normal....... Describe:
Days:              
 

SYMPTOMS

Symptoms Present Condition Describe
Aggravate During: Day Evening Night
Allergic to:  Alcohal Dust Other

Any Other  Problem :

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