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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