Fields * are required.
Name of the patient*
Age*	(Yrs.)
Sex	(Male / Female)
Weight	(Kg)
Height	(e.g. 5 feet, 7 inches)
Profession
Marital Status	(Married / Unmarried)
Email Address*
Complete Postal Address
City
State
Zip
Country*	Select Country India United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Bouvet Island Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatema la Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Latvia Lebanon Lesotho Liberia Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Norway Oman Pakistan Palau Panama Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Lucia Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Afr icaSpain Sri Lanka St Helena Sudan Suriname Swaziland Sweden Switzerland Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City S tate Venezuela Viet Nam Virgin Islands (British) Virgin Islands (US) Western Sahara Yemen Zaire Zambia Zimbabwe Other-Not Shown
1. Describe your main problems for which you want to seek our advice
2. For how long, are you suffering from these problems ?*
3. How is your physique ?	Fat Slim
4. How is your appetite ?	Good Poor
5. Do you have constipation ?	Yes No
6. Type of food that you eat.	Veg. Non–Veg.
7. Do you consume tobacco in any form ?	Yes No
8. Are you addicted to any other intoxicant (e.g., liquor/wine etc.) ?	Yes No
9. Do you take excessive quantity of tea or coffee ?	Yes No
10. Do you suffer from sleeplessness ?	Yes No
12. Do you feel any irritation or burning sensation while passing urine ?	Yes No
13. Do you feel palpitation of heart or pain in chest or breathlessness during physical exercise ?	Smooth Restricted
14. Are you a patient of High Blood Pressure ?	Yes No
15. If yes, mention your blood pressure.
16. Are you suffering from Diabetes ?	Yes No
17. If yes, mention Blood Sugar :	Fasting  PP  Random
18. Have you suffered from any disease earlier ?	Yes No
19. If yes, Name it.
20. If you have recently undergone a medical check-up pertaining to blood, urine, stool, sputum, any x-ray / ultrasonography, please mention the related reports.
21. Any other problem that you might like to state.
22. Is there  history of any hereditary disease in the family ?	Systolic Diastolic
23. If yes, mention it.