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]

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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”]

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

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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.

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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]

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Physical Activity / Exercises

 

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

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Any other specifications

[textarea otherspec]

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