| Reference
No : | |
| Name :* |
|
| Organization
: | |
| Street
Address : | |
| City : |
|
| State : |
|
| Postal code
: | |
| Country
: | |
| Telephone
: | |
| Fax
: | |
| E-mail
*: |
|
| Age
: | |
| Sex
: | |
| Height
: | |
| Weight
: | |
| Structure
: | |
|
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 details in brief : |
|
| 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 air, water, etc. |
|
| Treatment
done so far |
|
| Details
of Investigation/Medical Reports |
|
| Any
known Allergies : | |
| Other
information, if any: |
|
| Blood
pressure: |
|
|
|
