SREEKRISHNA
Ayurveda Panchakarma Center
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Name
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Nationality
:
Date on birth
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Height (cm)
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Weight (kg)
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Sex
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Male
Female
Profession
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Occupation
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E-mail
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Telephone
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Fax
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Marital status
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Married
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Present complaint with duration (most serious problem first)
Symptoms with duration 1
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2
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3
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4
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If already diagnosed - details
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Investigated details (if any)
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Investigation done –
details if available
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Diagnosis
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Drugs prescribed with dose
and how long taking them
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Diabetes Mellitus
High BP
Cancer
Arthritis
Asthma
Allergy
Sleep
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Appetite
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Bowel Habits
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Urination
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Addicted to
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Select if any
Tobacco
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Present diet - regime
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Message
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