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