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GENERAL FORM (Consultation for General / Systemic Diseases)
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| Fields marked with an asterisk (*) are required. |
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| *Name of the Patient |
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| *Age |
(Yrs.) |
| Sex |
(Male / Female) |
| Weight |
(Kg) |
| Height |
(e.g. 5 feet, 7 inches) |
| Profession |
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| Marital Status |
(Married / Unmarried) |
| *Email Address |
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| Complete Postal Address |
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| City |
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| State |
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| Zip |
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| *Country |
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*1. Describe your main problems for which you
want to seek our advice. |
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2. For how long, are you suffering from these
problems ? |
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| 3. How is your physique ? |
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| 4. How is your appetite ? |
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| 5. Do you have constipation ? |
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| 6. Type of food that you eat. |
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| 7. Do you consume tobacco in any form ? |
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8. Are you addicted to any other
intoxicant
(e.g., liquor/wine etc.) ?
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9. Do you take excessive quantity of tea
or coffee ? |
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| 10. Do you suffer from sleeplessness ? |
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| 11. Do you suffer from excessive urination ? |
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12. Do you feel any irritation or
burning
sensation while passing urine ? |
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13. Do you feel palpitation of heart or pain in
chest or breathlessness during physical
exercise ? |
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| 14. Are you a patient of High Blood Pressure ? |
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| 15, If yes, mention your blood pressure. |
Systolic / Diastolic |
| 16. Are you suffering from Diabetes ? |
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| 17. If yes, mention Blood Sugar : |
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| 18. Have you suffered from any disease earlier ? |
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| 19.If yes, Name it. |
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20. If you have recently undergone a medical
check-up pertaining to blood, urine, stool,
sputum, any x-ray / ultrasonography,
please mention the related reports. |
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| 21 Any other problem that you might like to state. |
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22. Is there a history of any hereditary disease
in the family ? |
Systolic / Diastolic |
| 23. If yes, mention it. |
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