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Name: |
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Age: |
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Sex: |
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Marital Status: |
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Height: |
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Weight: |
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Occupation: |
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Mail-id: |
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Phone No: |
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Address: |
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Discuss Your Problem: |
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Treatment: |
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Duration & Price: |
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30 Days (Rs.1000 or USD 25) 60 Days (Rs.1800 or USD 45)
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Duration & Price: |
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30 Days (Rs.2000 or USD 50)
60 Days (Rs.3600 or USD 90)
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Duration & Price: |
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30 Days (Rs.4000 or USD 100)
60 Days (Rs.7200 or USD 180)
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Duration & Price: |
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30 Days (Rs.8000 or USD 200)
60 Days (Rs.14400 or USD 360)
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Do you consume alcohol/tobacco in any form?: |
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Do you have any of these medical problems? High BP/Diabetes/Thyroid Dysfunction/Prostate: Enlargement/Cancer/Allergies |
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What types of treatment and medicine have you taken so far?: |
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What have been the results?: |
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Do you have any investigation report regarding your disease: |
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How is your appetite and digestion: |
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How often do you have constipation: |
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Do you sleep soundly: |
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Details of your home climate: |
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Are there any other detail you would like to share: |
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How did you hear about us?: |
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