Medical Questionnaire

Please fill in a detailed way for the medical team to assess the possibility of treatments.
A detailed report will also make the personal medical discussion more productive on the day of arrival.
Medical Details will be confidential with the medical team.
Old patients shall also fill in the current details however all your old records are available

Name

Age

Gender

Place of Residence

Chief Complaints

Complaint

Since: years/ months/weeks/days

Allopathic Diagnosis In Your Condition (if any)

History of your present complaints

How is your Appettite?

How is your Sleep?

Addictions/Habits if any

Do you have Bowel evacuations Every day?

Total Evacuations In a Day

What is your Occupation?

What is your nature of Work?

Medicine

Write either the generic name or Brand name with mg

The way in which it is taken. Example - one tablet twice daily after food

Medical conditions for which it is suggested

Other Information Which Might Be Helpful

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