Central India’s Hi-Tech Panchkarma Ayurvedic Hospital ....

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  Online Consultation
PATIENT PROFILE

Please fill up the following form
Last Name :
Middle Name :
First Name :
Address :
City :
State  
ZIP/PIN Code :
Country :
Country Area Local Code No. :
Tel. No.: [ Office ]     :
  [ Residence ]      :
Fax. No.: [ Office ]     :
  [ Residence ]      :
E-mail :
Nature of work / profession :


      
Working Hours :

Morning :
Evening :
Night :
Date of Birth : Date : Month : Year : Age : (Years Completed)
Sex :
Food Habit (Check all that apply)  : Vegetarian  Non-Vegetarian
    Alcoholic    Non-Alcoholic
    Drugs No-drugs
Constitution Of Body :                  Tall / Slim :   
Height : (Cms)                      Weight : (Kgs.)


      
NAME OF AILMENT :

Since how many years suffering 
Years  :          Months :      From Ailment / Disease ? 
Is it a : present time ailment  / Disease ?    
Name of Doctor, Hospital Consulted Before : 
Diagnosis :  
Recent treatment taking 


      
PLEASE TYPE IN THE PATHOLOGICAL REPORTS (s) :

X-Ray : : Urine :
Blood   : Stool :
Sonography : Scanning :
Whole Body Scanning : Any Other (Specify) :
Had You Been Operated Upon? :      
If Yes, Which Part of The :
Body / Organ :
Is There Any History Of
Bone Fracture ?
:
If Yes, Please Specify :