Demonstration
Interactive Web Form

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First name:

Last Name:

E-mail:

Login Name: Password:

Sex: Male or Female

Age:

Simptoms:

What is the global affection you think that you have?

What is the other affection you think that you have?

Please answer the following questions:

Have you consulted a physician?

Yes, I have consulted a physician
No, I have not consulted a physician

If you have consulted a physician, please type into the box below the diagnostic:



Did you follow the tratament?
Yes, but I was not treated
Yes, I was satisfied with the treatment applied
Yes, but I am not feeling better after the treatment
No

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