General Consultation

How is your physique ?

Fat

Slim

How is your appetite ?

Good

Poor

Do you have constipation ?

Yes

No

Type of food that you eat.

Veg.

Non-Veg.

Do you consume tobacco in any form ?

Yes

No

Are you addicted to any other intoxicant (e.g., liquor/wine etc.) ?

Yes

No

Do you take excessive quantity of tea or coffee ?

Yes

No

Do you suffer from sleeplessness ?

Yes

No

Do you suffer from excessive urination ?

Yes

No

Do you feel any irritation or burning sensation while passing urine ?

Yes

No

Do you feel palpitation of heart or pain in chest or breathlessness during physical exercise ?

Yes

No

Are you a patient of High Blood Pressure ?*

Yes

No

Are you suffering from Diabetes ?*

Yes

No

If yes, mention Blood Sugar

Have you suffered from any disease earlier ?

Yes

No