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Please answer the following questionnaire:
Question 1. Have you had the following case history? Please tick box and any relevant information that may apply to you.
 
 
 
 
 
 
 
 
 
Question 2. Past History (Previous ailments and surgery)?
Question 3. What is your main health concern/complaint?
Question 4. Have you had any accidents in the last 5 years?
Question 5. Do you have any chronic illness?
Question 6. Do you currently have any contagious disease?
Question 7. Do you have any allergies?
Question 8. Do you have a weak appetite or lack of thirst?
Question 9. Duration of current symptoms? How did the symptoms develop?
Question 10. Addictions?
Question 11. Any known cause to you for the disease?
Question 12. State of digestion, micturition, appetite and sleep:?
Question 13. Treatments to date?
Question 14. Recent investigations reports (blood, urine, stool, x-ray, CT scan etc:) ?
Question 15 Your individual problems:
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