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*Name:
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*Address: |
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*Age: |
*Sex:
*Occupation:
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*Phone: |
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Fax: |
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*Email: |
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Symptoms: |
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Tremors |
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Slow Movement: |
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Rigidity
Stiffness:
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Micrographia: |
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Speech Difficulty:
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Reduced swings: |
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Gait
Problem:
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Short
Stepped: |
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Shuffling
Leg:
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Difficulty
in
Getting Up: |
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Joint
Pain:
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Postural Instability: |
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Blinking Eyes: |
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Dryness:
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Itching:
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Hard to
Swallow Food: |
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Difficulty
in Sleep: |
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Pain during
Sleep:
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Nightime
Urination: |
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Nightmares:
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Rapid
or
Pounding Heart: |
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Dryness
of Skin: |
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Confusion: |
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Mood
Changes:
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Depression: |
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Sadness:
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Nausea: |
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Heartburn:
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Constipation: |
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Dry Mouth:
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Sexual
Dysfunction: |
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History
including medical and surgical: |
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Present
Complaints: |
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Symptoms,
Duration and Previous Diagnosis: |
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Alcohol: |
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Smoking:
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Tobacco: |
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Drugs:
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Non Vegeterian: |
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Vegeterian:
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Other
Habits: |
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Family
History
and Other Investigations: |
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Diabetes,
Hypertension - CNS findings in brief (Muscle Tone, Power,
Reflexes, Involuntary Movement): |
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Difficulty
in achieving and maintaining an erection? |
Prostate: |
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Thyroid:
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Fatigue: |
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Weight
loss:
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Current
Medications: |
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Comments: |
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