General ConsultationFields marked with * are compulsory.


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* 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

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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:
 

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