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Status Report

 
We treat the root cause, not just the symptoms.
 
 
Please fill the form & submit : *required

 Personal Details :

 
*Name :  
*Emai :  
*Country :  
*Age :  
*Sex :  
Male Female
*Height :  
*Weight :  
*Postal Address :  
*Profession :  
*Phone :  
       
*Please prove that you are human, by giving the answer :  
 Measurement
       
Chest :   Weist :
Stomach :   Hips :
Arms :   Height :
             
       
 History - Disease
       
Any major Operation ? :  
Yes No
Thyroid Disorder :  
Allergies :  
Prolonged Use Of Steroids :  
Diabetes :  
Blood Pressure :  
Stress / Depression :  
Any chronic problem :  
*Current compaints :  
*Constipation :  
Yes No
       
 Weight
       
At the time of puberty :  
Before 5 years :  
Before 1 year :  
Before 6 months :  
Before 3 months :  
*At present :  
Where the weight records were taken :  
Ideal desirable recommended weight :  
Weight Category    
According to the patient reason for Lessweight :  
When did you notice that you are underweight? :  
Have you ever tried to increase your weight if yes than give details :  
Family history of under weight :  
If Yes, please furnish details :  
Associated Symptoms :  
       
 Diet Schedule :
       
        TIME  
INTAKE OF FOOD
*Wake Up :    
*Breakfast :    
*Lunch :    
*Supper :    
*Dinner :    
       
Schedule of Lifestyle :
       
        TIME mor / eve   Mins. / hrs. given
*Yoga :    
*Exercise :    
*Walking :    
*Gymnasium :    
*Other exercise :    
       
 
 
Welcome to Family Care Clinic

DISEASES / TREATMENTS
Skin Cosmetics
Natural Fitness Capsules
Weight Loss N Personal Care
Hair cosmetics
Welcome to Family Care Clinic
 
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We are authentic registered clinic, Licence No: GBI 12296. Our Import Export Code No: 0802005365
**Any dispute subject to the jurisdictions where the Clinic Located.
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