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Dr Stuti Khare Shukla
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Patient Medical Declaration Form
Connected with Case Manager (required)
Connected with
Ami
Bharti
Lavneet
Veena
Bhagyashree
Shubham V
Rajendraji
Mamata
Full Name (required)
Age (required)
Gender (required)
Select option
Male
Female
Others
Date of Birth (required)
Occupation -(required)
Weight in KG
Blood Group Select one (required)
Select option
A RhD positive (A+)
A RhD negative (A-)
B RhD positive (B+)
B RhD negative (B-)
O RhD positive (O+)
O RhD negative (O-)
AB RhD positive (AB+)
AB RhD negative (AB-)
Marital Status (required)
Select option
Unmarried
Married
Address: Full address (required)
City - (required)
Contact Number (required)
Your Email address (required)
Emergency Contact & Phone number
REFERRED BY
Social Media
---
Google
Youtube
Facebook
Twitter
Instagram
Blog/Articles
Yahoo
Bing
Other
Friend/Relative
Newspaper/Television/Magazin
MEDICAL HISTORY
Diabetes - Do you have Diabetes? (required)
Select option
Yes
No
Not Applicable
Hyper Tension (required)
Select option
Yes
No
Not Applicable
Heart Disease - Do you have Heart Disease (required)
Select option
Yes
No
Not Applicable
Neurological or Psychiatric issue? (required)
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Not Applicable
Neurological
Psychiatric
Allergies (Any Specific Medication)
Others
Are you on medications currently, if yes then mention their details
Are you planning a family in near future, if yes then within how many months
For females, are your periods regular, if not, are you aware of hormonal issues or PCOD
Do your parents or other family members also suffer from hairloss or skin issues?
Any other genetic or other type of specific disease, you are aware of?
Have you been seen by any Dermatologist or Plastic Surgeon in the past, if yes, please attach your previous prescriptions or please elaborate about the past treatment details. - ie: If any?
PAST SURGICAL HISTORY
Surgery Name
Dr.Details
Specific information
Date
PERSONAL HISTORY
Diet
Select option
Vegetarian
Non-Vegetarian
Lifestyle
Select option
Sedative
Workout Sometimes
Regular Excercises
Any issues related to constipation, acidity
Select option
Yes
No
Any history of recent Stress/Viral fever/acute disease
Select option
Yes
No
Current Hair & Skin Routine (if any)
Smoking, if yes, how many cigarettes per day
Any supplements you are consuming
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