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Name*
Age*
Sex*
- Male
- Female
Matrial Status*
- Married
- Unmarried
- Never Married
- Divorced
- Widowed
Phone No*
Email*
Height*
Weight*
Residential Address*
Country*
Briefly Explain Your Health Problem*
Nationality*
- Indian
- NRI
- Foreigner
Addiction if any*
- Yes
- No
Diet Habit*
- Veg
- Non – Veg
- Vegan
- Lactovegetarian
- Oovovegetarian
Have you Been Treated in this Hospital Earlier*
- Yes
- No
How far you have been able to adopt naturopathy in daily life?*
- Almost Every Day
- Occasional
- Very Rare
Physical Activity Profile*
- Exercise
- Yoga
- Walking
- Gym
How frequently you consume fresh fruits,raw vegetables ?*
- Almost Every Day
- Occasional
- Very Rare
Emergency Contact Person Name*
Their Relationship*
Upload your medical reports if any
Emergency Contact Person Number**