| Reference No |
|
| Name |
A value is required. |
| Occupation |
|
| Address |
|
| |
|
| Street Address |
|
| |
City |
Province/State |
|
|
| |
Postal/Zip code |
Country |
|
|
| Phone No. |
|
| Fax |
|
| E-mail |
A value is required.Invalid format. |
| Age |
|
| Sex |
Male
Female |
| Height |
|
| Weight |
|
| Body Type |
Obese
Lean |
Nature of work:
Whether it
involves onstant
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 |
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| |
|
| 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
|
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| |
|
| Treatment done so far |
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| |
|
Details of Investigation / Medical Reports |
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| |
|
| Any known Allergies |
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| |
|
Other information, if any
|
|
| |
|
Details of Allopathic Medicines using at Present
|
|
| |
|
| Details of lab reports Available |
|
| |
Blood Sugar |
|
| |
Urine Sugar |
|
| |
HDL |
|
| |
LDL |
|
| |
VLDL |
|
| |
Blood Pressure |
|
| |
Hb |
|
| |
Blood group |
|
| |
SGOT |
|
| |
SGPT |
|
| |
Bilubin Total |
|
| |
Bilubin Direct |
|
| |
Creatinine |
|
| |
Srm pottassium |
|
| |
Srm Sodium |
|
| |
|
| Any additional information or remarks |
|
| |
|
| N.B : Furnish the information available only and not all columns are mandatory. |
|
