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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