Patient Information
Please fill in all the details
Name?
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Age?
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Gender
Weight?
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Height?
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Date of filling the form?
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Date of Birth
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Contact Number?
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Your Address
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Your profession and your working hours?
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Name of the disease you are suffering from?
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Names of all the medicines you are taking currently?
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From how long you are taking these medicine?
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Mention the symptoms or discomfort that you are suffering from?
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Please Mention the blood pressure measured recently and what was the date?
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Please mention the Blood Sugar Fasting level as well as PP last measured and their date?
Your answer
Please mention the cholesterol level recently measured and the date of test?
Your answer
Please mention the TSH, T3, T4 levels last measured and date of test? (If you are suffering from Hypo or Hyper Thyroid)
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Do you suffer from any kind of ache or pain?
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Do you suffer from any of the stomach problem?
(The problem related to stomach you notice daily)
Family History
( Name of the disease that anybody in your relation is suffering from and your relation with that person)
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What is the first thing that you have after you wake up?
( Water, medicine, tea, milk or anything else)
Your answer
Mention the approximate time of your breakfast?
Your answer
Name the food items that you generally have in your breakfast?
(Sabzi + dal + roti + milk sometimes boiled egg or bread)
Your answer
What you have in Morning Snacks (In between breakfast and lunch)
Your answer
Mention the approximate time of your Lunch?
Your answer
Mention the food items you generally have in your Lunch?
Your answer
Mention the place where you have your Lunch?
At home or at your work place
Your answer
Mention the approximate time of your snacks?
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Mention the food items that you generally have in your snacks?
(For eg: tea, biscuits, namkeens, samosa, pao bhaji others)
Your answer
Mention the approximate time of your dinner?
Your answer
Mention the food items that you generally have in your dinner?
( At 8:00 pm 2 roti, sabzi, dal, rice, salad, curd)
Your answer
Mention the place where you have your dinner?
( At home or at work place)
Your answer
Mention the time and what all things you generally have before going to sleep?
At 10:00 pm milk, tea, coffee
Your answer
Allergy to any food item?
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Please specify your chewing ability?
Mention the total hours of sleep?
mention differently in day as well as in night?
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Which of the following reflects your daily mood?
Mention the time duration exercise/yoga/gym/any other physical activity you do in a day?
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How do you get to know about us?
Who filled this form?
Anything else you want to say?
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