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Full Name
Email
Age
Marital Status
City of birth
City of residence
Ocupation
Family illness
Diabetes
Hypertention
Cancer
Kidney Desease
Mental illness
Weight
Height
Do you smoke or have you smoked?
Yes
No
Have you had previous surgeries?
Yes
No
If you answered yes in previous surgery
Have you used illegal drugs?
Yes
No
If you answered yes in illegal drugs
Are you pregnant?
Yes
No
Number of living children?
Method of birth control?
Number of caesarean sections
Cancer
Heart Diseases
High blood pressure
Kidney Diseases
Mental Illness
Tuberculosis
Convulsions
Asthma or Bronchitis
Castric Ulcers
Hepatitis
Blood diseases
Palpitations
Glaucoma
Parasites
Anemia
Arthritis
Do you require?
Stick
Crutches
Wheelchair
Walker
Special Cutlery
Special Chair
Adapted
Others
List the medication you take
Allergies?
In case of emergency, a Name and Contact Number (Preferably family)
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