Health Assessment Form

Please fill out all sections to complete your comprehensive health assessment

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Personal Details

Basic information about yourself

Full Name *

Age *

Gender *

Height (cm) *

Weight (kg) *

City/Location *

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Symptom Details

Detailed information about your symptoms

Primary Symptom *

Secondary Symptoms

Duration *

Severity *

Pain Scale (0-10) *

0 (No pain) 0 10 (Severe pain)

Onset Type *

Pattern *

Triggers

Relieving Factors

Affected Body Area *

Progression *

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Medical History

Your past and current medical information

Pre-existing Conditions *

Specify Other Condition

Past Surgeries

Family Illness History *

Allergies *

Allergy Details

Current Medications

Previous Similar Symptoms

Pregnancy Status

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Lifestyle

Your daily habits and lifestyle factors

Diet Pattern *

Sleep Hours (per night) *

Water Intake (per day) *

Smoking Habit *

Are you taking Gym supplements? *

Alcohol Consumption *

Physical Activity Level *

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Additional Context

Any other relevant information

Recent Travel

Exposure to Sick People *

Stress Level *

Additional Notes

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Blood Report (PDF Upload)

Upload your blood report PDF for automatic value extraction

Upload blood report (PDF)

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