Please submit your History in the format given below. Try to give detailed, correct and updated information. Mail your completed history form to info@ayurvedaphysician.com
Personal Details:
Name:
Age: (years)
Sex: Male / Female
Marital Status: Single / Married / Divorcee / Other
Nationality:
Height: feet / inches
Weight: Kilograms
Blood pressure:
Dependence on: Alcohol / Drugs / Smoking / Tobacco / Coffee / Tea
Education:
Profession:
Address:
Tel. Nos.:
E-mail:
Medical History:
Chief Complaint:
(with duration)
Other Complaints:
(with duration)
Detailed History:
Family History:
Laboratory and Other Investigation Reports:
Any Known Sensitivity / Allergy:
Medication Details:
Current:
Past:
Any Other Important / Relevant Information:
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