| * Name of the Patient: |
|
| * Age: |
(Yrs.) |
| * Sex: |
|
| Weight: |
(Kg) |
| Height: |
(e.g. 5 feet, 7 inches) |
| Profession: |
|
| Marital Status: |
|
| * Email: |
|
| Complete Postal Address: |
|
| City: |
|
| State: |
|
| Zip: |
|
| * Country: |
|
* 1. Describe your main problems for which
you want to seek our advice: |
|
2. For how long, are you suffering
from these problems ? |
|
| 3. Do you have constipation ? |
Yes No |
4. Are you addicted to any other
intoxicant (e.g., liquor/wine etc.) ? |
Yes No |
| 5. Do you suffer from sleeplessness ? |
Yes No |
| * 6. Are you a patient of High Blood Pressure ? |
Yes No |
| 7. If yes, mention your blood pressure: |
(Systolic / Diastolic) |
| * 8. Are you suffering from Diabetes ? |
Yes No |
| 9. If yes, mention Blood Sugar |
Fasting
PP
Random
|
10. Have you suffered from any disease
earlier ? |
Yes No |
| 11. If yes, Name it: |
|
12. If you have recently undergone a medical
check-up pertaining to blood, urine,
stool, sputum, any x-ray / ultrasonography,
please mention the related reports. |
|
13. Any other problem that you might
like to state. |
|
14. Is there a history of any hereditary
disease in the family ? |
(Systolic / Diastolic) |
| 15. If yes, mention it: |
|
| |
|
