Quick Check

1
Contact details* This field is required.
2
Gender* This field is required.
Male
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3
What exactly is/are the Problem(s)* This field is required.
Itching
Rashes
Pain
Colouration
4
Others specify* This field is required.
5
When did this problem start?* This field is required.
6
What parts of the body are affected?* This field is required.
7
Is this the first time you are having this type of problem?* This field is required.
8
Do you have any personal or family history of allergies like Asthma, very itchy eyes?* This field is required.
9
Were you taking any drug for any other reason before onset of rash?* This field is required.
10
Which previous medications have you used for this problem?* This field is required.
11
What was the response after using the medications?* This field is required.
12
Do you suffer from any other health problems?* This field is required.
13
Upload Photo at arms length* This field is required.Focused picture
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14
Upload Photo taken up close* This field is required.Overview picture
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15
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