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Nature of work: Whether it involves constant traveling, etc:

Present complaints with full history :

Has the patient or his/her near relatives had such complaint? (Hereditary factor) if so, furnish det

Any cause known to you for the disease :

Any history of venereal disease, malaria, filaria or any other noticeable ailments:

State of Appetite, Digestion, Motion, Urine, Sleep:

Dietary habits :
Vegetarian or non vegetarian food articles being taken and their timings.

Addiction to smoking, alcohol, etc:

Marital status-married or unmarried. Number of issues. Menstruation, delivery, etc, problem if any:

Climate & present weather conditions of the place where he/she lives. Any problem of pollution of ai

Treatment done so far

Details of Investigation/Medical Reports

Any known Allergies :

Other information, if any:

Blood pressure:

Will you be interested to take treatments in Kerala in any of our hospitals or resorts?

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