Name of Patient Age Gender MaleFemaleTransgender Your Email Address Contact Number Address Current Complaint Associated Issues (if any) DiabetesThyroidHypertensionCardio-vascular issuesMusculo-skeletal issues (slipped disc, disc- bulge, etc) Any other issue (if any) Family History DiabetesThyroidHypertensionCardio-vascular disordersArthritis Any other issue (if any) Any recent surgical procedure history:
