General Consultation Form

Keralaayurvedashram Medicines & Superfoods Pvt.Ltd.

Crystal Hospital Building, Maratha Colony, Wamanrao Sawant Road, Dahisar (East),
Mumbai-400068, India. Mobile :+91-9892687120
E-mail:keralaayurvedaashram@gmail.com
Branch: DD Angadi Building, Convent Junction, Market Road, Kochi-682011, Kerala

Note-1): You can skip any number of points, which is not seems to be relevant to you.
Note-2): (*) donate mandatory points.

Name of the Patient (*): Age (*): Sex (*) :
Male Female Other
Email (Mandatory) : Weight: Height:
Patient's Mobile No (*).
Residential Address:
Designation:
Office Address:
Medical History
Appetite:
Walking Style:
Bowel Habits:
Joints:
Memory:
Voice:
Working Capacity (Stamina):
Approach to New Events:
Temper:
Sleep Pattern:
Speed of Work:
Favourite Climate:
Food Taste you like:
Type of Food:
Skin Texture:
Eye Ball Colour:
Hair Pattern:
Basic Nature:
Nail Pattern:
Body Make-up:
B.Allergy to (*): Dust Smoke Smell Cold Food Other (Please Specify)
C.Habits / Addiction (*): Tobacco Alcohol Other (Please Specify)
D.Existing Diseases (*): Diabetes Heart Asthma Blood Pressure Arthritis Kidney Other (Please Specify)
E. Recent Test Result
Blood Sugar
FBSPLBS
Heart
Total Chol.HDL Chol. LDL Chol.Triglycerides
Blood Pressure
SYS.DIA.
Kidney
HB.BL. UREA CreatinineUrine Albumin
F. History of Past Illness (Last 5 Years)
No. Diagnosis Days-Hospitalised Surgery Undergone Regular Medicines Taken Remarks
G. History of Present Illness:
H.Diagnosis: