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  Name of the patient*
  Gender
  Male Female  
  Full address
   
  Phone*
  Email*
  Height
  Cm   Weight  Kg
  Short description of present complaint
  Duration of complaint
  Type of medications used
  Blood Pressure
  Bp   Sugar Level  Mg/dl
  Short description of past problems and medications used
  Detail existence of problems like diabetes, hypertension, cardiac problems
  For women, please give menstrual history
  Type the charaters you seen in the picture
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