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Details of the Patient
Name
Gender
Date of Birth
*
required
Phone Number
Email
Diagnosis(In brief)
Patient requirements
Ventilator
Yes
No
Tracheostomy
Yes
No
Foleys
Yes
No
Ryles
Yes
No
Bed Sore
Yes
No
Can stand independently
Yes
No
Conscious
Yes
No
Preferred Location for Rehabilitation
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