Patient’s Info

Name* Age* Sex

Address*

Tel* Email*

Occupation* Nature of Work
DeskworkField Work

Present Complaints* Previous history of illness (if any) with time period Family History
HypertensionDiabetesAny other

Details of present drugs/medications (if any) Treatment requested for

Diet Routine


Meals RegularIrregular   |VegNon-Veg
Alcohol Intake YesNo
Tobacco Intake YesNo
Water Intake Per Day   glasses    ltr.

Diet table


Time Diet
Breakfast
Mid-Morning
Lunch
Evening Tea
Dinner

Physical Activity / Exercises


Time Exercise Duration
Morning
Evening

Any other specifications

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