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Health Questionnaire

Name

S/o, W/o

Work Address

FAX

Age

Weight

Veg: Non-veg:

Smoking

YesNo

Alcohol

YesNo

Details of disease:

Food habits till date:

Morning:

Noon:

Evening:

Night:

Methods of treatment taken:

I would like to take your advice and live healthy free of diseases.
Yours
P.S: Your comments and opinions on the stage after disease is cured.