Patient Registration

What's your first_name?
What's your Surname?
What's your email?
What's your parent detail?
What's your parent name?
What's your patient DOB?
What's your patient age?
What's your patient address?
What's your telephone number?
What's your telephone number2?
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Problem Yes No
Back pain
Fever
Normal check up
High blood pressure
Diabetes
Dental problem / tooth ache
Jaw pain/Joint pain
Wisdom tooth
Other (please specify)
What's your parent address?
Problem Yes No
Breathing problem (Asthma)
High blood pressure
Fever /Cough
Diabetes
Heart problems
Kidney problems
Bleeding problems
Epilepsy (Fit)
Gastro intestinal problem
Other
What's your Weight ?
What's your height ?
What's your blood group ?
  • What's your Cholesterol?
    What's your blood sugar?
    What's your Blood pressure ?
    What's your Heart Rate?

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    What's your Drugs ?

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    What's your radilogy views ?

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    What's your image1?

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    What's your image2?

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    What's your image3?

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    What's your image4?

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    What's your image5?

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    What's your image6?

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    What's your image7?

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    What's your image8?
    What's your username?
    What's your mobile no?
    What's your password?