Patient Registration Form FULL NAME * PHONE * DATE OF BIRTH* GENDER * MALEFEMALETRANSGENDER MARITAL STATUS * MARRIEDUNMARRIED E-MAIL ADDRESS ANY FAMILY HISTORY OF VITILIGO/PSORIASIS HEREDITY FROM METERNALPATERNAL CONSUMPTION OF OUT SIDE FOOD/WEEK HABITS OF TAKING MILKFRUITSDRY FRUITSCHOCOLATEHONEYCOCONUT ADDICTION TEACOFFEESOFT DRINKALCHOHOLSMOKING EXERCISE YOGYAPRANAYAMMORNING WALKAEROBICSGYM HISTORY OF ANY PAST DISEAESE IF YES, ANY MEDICATION ON IT ? WEIGHT IN KG'S HEIGHT IN CSM SWEATING MILDEXCESS HAIR FALL YESNO TREATMENT REQUIRED * VITILIGOPSORIASISHAIR CAREBEAUTY CARE INVESTIGATION ANY OTHER SPECIFIC PROBLEM UPLOAD PHOTO
