Name
Sex
Male Female
Born On
Occupation
Contact No.
Address
Email
Marital Status
Married
Unmarried
Single
Divorcee
Education
Height
Feet Inches
Weight
Kilograms
Main Complaint
(Onset of Complaints,Periodicity,Severity etc.)
History of Complaints
Past History
Family History
Food Habits
Breakfast
Lunch
Dinner
Others
Dependence on
Alcohol
Drugs
Smoking
Coffee/Tea
Urine Output
Regular
Burning
Scanty
Frequent
Bowels
Constipated
Watery
Tongue
Clear
Coated
Appetite
Less
Heavy
Sleep
Disturbed
Emotions
Expressive Non expressive
Blood Pressure
Pulse
/ per minute.
Laboratory Investigation Reports (if any)
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