Adheenavasi Medical History Form
Fill this form if you have decided to become Adheenavasi and you will be arriving for Sadashivatva program starting May 13th. The purpose of this form is to have a clear understanding of your medical history and medical requirements.

if you are joining adheenam as a family, you need to fill this form for each person in your family.

* Required

ID No.
if you havent received ID no, ensure you have filled http://tiny.cc/sadashivatvaidform. If you have filled the form already, and still havent received the ID no, you can enter "filled ID form, waiting for ID no"/
Your answer
First Name
Your answer
Last Name
Your answer
Age
Your answer
I am allergic to:
Your answer
I have these medical conditions: (if more than one condition please state clearly. If None, write None):
Your answer
I am taking these medications: Please state medical condition next to each medicine, eg. Ibuprofen 20 mg. - Severe Headaches
Your answer
I have acquired or been exposed to infectious/ communicable diseases diseases in the last 2 years.
If Yes, please explain
Your answer
Diagnosis
Your answer
Date of onset
MM
/
DD
/
YYYY
Date of last visit
MM
/
DD
/
YYYY
Please describe the physical limitations on your ability to conduct major life activities due to the medical condition.
Your answer
Please describe any side effects of prescription medication that may interfere with your daily duties.
Your answer
Medication / Effects
Your answer
Medication / Effects
Your answer
If this is a chronic condition, please describe frequency of episodes, if known.
Your answer
What is the expected progression or stability of the diagnosis?
Your answer
How often do you need a review with a doctor for your condition?
Your answer
Please include any other information which you believe would be useful in determining appropriate assistance for you staying at the Adheenam
Your answer
I have the following special needs (physical, dietary):
If None, write None.
Your answer
Blood Type:
Your answer
Other information regarding my health that a doctor should know:
If None, write none.
Your answer
EMERGENCY CONTACT: In case of Medical emergency, please state your Doctor's contact information here. (Name, Tel. No., e-mail)
Your answer
Please state the contact information of 2 relatives who should be contacted in case of an emergency. (Name, Tel. No., e-mail)
Your answer
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