Name* Age* Sex Marital Status
[text* your-name] [text* your-age] [select sex “Male” “Female”] [text* marital_status]
Height Weight Occupation* Nature of Work
[text height] [text Weight] [text* occupation] radio natureofwork default:1 “Deskwork” “Field Work”]
Address* Tel* Email*
[textarea* address] [text* tel] [email* your-email]

Present Complaints and their duration* Previous history of illness (if any) with time period Family History
[textarea* presentcomplaints] [textarea previoushistory] [radio familyhistory default:3 “Hypertension” “Diabetes” “Any other”]

Details of present drugs/medications (if any) Treatment requested for
[textarea presentdrugs] [textarea treatmentrequested]

Diet Routine


Meals [radio meals1 default:1 “Regular” “Irregular”]   |[radio meals2 default:1 “Veg” “Non-Veg”]
Alcohol Intake [radio alcohol default:2 “Yes” “No”]
Tobacco Intake [radio tobacco default:2 “Yes” “No”]
Water Intake Per Day [text waterintake1]  glasses  [text waterintake2]  ltr.

Diet table


Time Diet
Breakfast [text breakfasttime] [text breakfastdiet]
Mid-Morning [text midmorningtime] [text midmorningdiet]
Lunch [text lunchtime] [text lunchdiet]
Evening Tea [text eveningteatime] [text eveningteadiet]
Dinner [text dinnertime] [text dinnerdiet]

Physical Activity / Exercises


Time Exercise Duration
Morning [text morningtime] [text morningexercise] [text morningduration]
Evening [text eveningtime] [text eveningexercise] [text eveningduration]

Any other specifications
[textarea otherspec]

Please Enter the captcha code below
[captchar captcha-860] [captchac captcha-860 size:m]

[submit “Send”]