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"/
First Name *
Last Name *
Age *
I am allergic to: *
I have these medical conditions: (if more than one condition please state clearly. If None, write None): *
I am taking these medications: Please state medical condition next to each medicine, eg. Ibuprofen 20 mg. - Severe Headaches *
I have acquired or been exposed to infectious/ communicable diseases diseases in the last 2 years. *
If Yes, please explain
Diagnosis
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.
Please describe any side effects of prescription medication that may interfere with your daily duties. *
Medication / Effects
Medication / Effects
If this is a chronic condition, please describe frequency of episodes, if known.
What is the expected progression or stability of the diagnosis?
How often do you need a review with a doctor for your condition?
Please include any other information which you believe would be useful in determining appropriate assistance for you staying at the Adheenam
I have the following special needs (physical, dietary): *
If None, write None.
Blood Type: *
Other information regarding my health that a doctor should know: *
If None, write none.
EMERGENCY CONTACT: In case of Medical emergency, please state your Doctor's contact information here. (Name, Tel. No., e-mail) *
Please state the contact information of 2 relatives who should be contacted in case of an emergency. (Name, Tel. No., e-mail) *
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This form was created inside of Nithyananda Dhyanapeetam.