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    Does your complaints aggravate during (please tick)
    ExertionExerciseNormal activityAny otherRest




    Present complaint with duration (most serious problem first)
    Symptoms with duration




    Investigation done – details if available


    Diagnosis


    Drugs prescribed with dose and how long taking them



    Most recent tests done

    X-ray Urine Analysis Stool Exam
    Colonoscopy Lipid profile PSA
    Blood Sugar H.crit Bun
    Uric Acid Hb MRI
    CT

    Additional Details



    Details of children

    For Females (Menstrual Cycle)