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 Medical Profile    ALLERGIES & LIFESTYLE 
Step 4 of 5   -   Enter Allergies & Lifestyle
 
Although this form is not mandatory, please fill in maximum details for a more informed and accurate consultation from your consulting MD.

Medication Allergies
Enter Medication Allergies, if any. [Please be precise about Medication Allergies.]

Lifestyle
Tobacco consumption
Yes No

I smoke...

Cigarettes

Cigars

Pipe

Chewing Tobacco

Other

How long have you been consuming to tobacco? yrs

Daily consumption quantity [Eg: 1 packet of cigarette daily etc.]
Alcohol
Yes No
Alcohol Since yrs
Daily consumption ml
Type Of Alcohol
How long have you been chewing tobacco ?
Yes No
Since yrs
Drug Abuse
Yes No
Addicted for yrs
Abuse Description
Late Nights
Yes No

Daily

Weekly

Twice a month

Rarely
Sleeping Pattern
Work Involves

Physical Labor

Normal Work

Mental Stress

Retired

Enter details about type of work, Industry etc.
How many times a day you urinate?

Any other information please enter below.
Do you have regular Bowel movements?
Yes No
Any other information please enter below.



 
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