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Date Of Birth*:
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Blood Group:
Fasting Blood Sugar:
Pulse (count/per minute):
Urine :
Bowels :
Appetite :
Sleep without pills or with pills:
Sleep and wake up time :
Do you have sleep apnea/ snoring:
Energy Levels:
Complaints & Duration :
Reports & Investigation if any :
Present Treatment :
Have you ever received Homeopathy or Ayurveda Treatment?:
Naturopathy or Ayurveda Treatment in residential hospital?:
History of major illness and Surgery :
Family History:
Provisional Diagnosis :

Diet & Lifestyle History

1) Processed/ Preserved/Frozen Food intake ? :
2) Fruits/Veg/Salad intake ?:
3) Water / Liquid intake per day (litres):
4) Tea/ Coffee intake per day (cups):
5) Soft drinks/ Beverages intake per day (ml):
6) Alcohol intake (ml):
7) Smoking/Drug :
8) Food Supplements :
9) Exercise Routine :

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