NAME:

AGE:

D.O.B

Phone No:

Email:

Address:

Gender
Male
Female

Medical Information

Past Disease

Blood pressure
Diabeties
Obesity
Heart issue
Phobia
Any kind of Allergies

Body Measurement

Make sure you stand straight

Inches

Kg

Current Symptom's

What is your Main Symptom?

Headache
Nausea
Fever
Dizziness
Fatigue