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Theraputic Form
Select the disease (*)
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Email (*)
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Name (*)
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Country of residence (*)
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Sex (*)
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Nature of job (Press "CTRL" key to multiple selection)) (*)
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Details of disease conditions you are suffering

Time period (*)
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Other informations
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Categorization of pain (*)


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Describe the causes of disease and why it becomes serious (*)
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Previous disease conditions?
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What are the surgeries you have been undergone
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Your food habits (It is important to mention the content of food, if you are aware about that. eg : bun, wheat flour)
What you had for your breakfast (*)
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What you had for your lunch (*)
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What you had for your dinner (*)
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Do you have any food allergies (*)

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Select the tastes as your preference





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Life style
When you go to bed (*)
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When you wakeup (*)
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Do you have a continous sleeping (*)
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What do you do for exercises and duration (*)
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Addictins and habits (*)
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Do you take alcohol frequently
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Amount you take per day
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Do you smoke
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Height (*)
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Weight (*)
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Size arround your belly (*)
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Do you have hereditary diseases (*)
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Does your family have hereditary diseases (*)
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Number of times you urinate
Day (*)
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Night (*)
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Color of urine (*)
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Are there any smell of urine (*)
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Number of times you stool
Appetite (*)




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Day (*)
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Only for Female

Night (*)
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Age of puberty (*)
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Nature of stool
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Do you have a regular menstrual circle from the day of puberty (*)
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How often menses is happened (*)
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How many days menstrual period exists (*)
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Do you have any pain at menses (*)
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Describe the nature of the pain
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Nature of menstrual blood
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Number of pregnancies
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Number of children
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Number of Gastronomy
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Attach your reports as a Zip file
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Please enter these numbers
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