On line Application for Ayurveda Treatment
 

Health History Questionnaire
Personal Details
Name :
Age :
Sex :
Marital Status :
Contact Address :
E-mail Address :
Occupation :
Family Background :
Case Details
Presenting complaints :
History of illness :
Hereditory or Not :
Treatments/ Medication undergone :
Diagonostie test done, if any :
Surgery undergone, if any :
Other hospitalisation , if any :
Mental Health (Depression, Stress, Fear etc.,) :
Related Information
Sleep :
Appetite :
Bowel Movements :
Urine :
Digestion
Sweat
Vegitarian or Non- Veg
Habits
Use of alcohol
Smoking
Drugs
Type of food
Food habbits/ timings
Exercise, if any
Any Other Information
      

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