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* Indicates required question
Age
*
Your answer
Sex
*
Choose
Male
Female
Other
Did u suffer from any medical condition? Mention below
Your answer
Did u take medication? Mention below the names u remember.
Your answer
Did u go to doctor for the treatment of above condition?
*
Yes
No
Other:
Required
Were you cured by the treatment?
*
Yes
No
Other:
Required
Were you hospitalized for the above condition?
Yes(Government Hospital)
No
Yes(Private Hospital)
Other:
How long were you hospitalized for the above condition(Days)?
Your answer
Have you undergone any surgery? If yes mention it
Your answer
Any Side effect/Problem of surgery you want to mention?
Your answer
Anything that you want to suggest?
Your answer
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