School of Ayurvedaconsultant.Guru Patient Name: * Age * Sex * -Select- Male Female Address * Contact No. * Religion * -Select Religion- Hindu Muslim Other Marital Status * -Select Marital Status- Married Single Education * -Select Education- Literate High School Graduation Socio Economic Status * -Select Status- Low Middle High Occupation * -Select Occupation- Professional Service Student Housewife Height/Weight/Pulse/BP Present Problem Email id Past History Checkboxes Hypertension Heart disease Diabetes Kidney disease Thyroid disease Cancer Any other disease? Past surgeries Other Disease Mention Past Surgeries... Systems Review Skin (Ex. Rashes,Lesions) Yes No Eyes (Ex. Eye pain/burning, loss of vision,double vision) Yes No Constitutional (Ex. Fever,weight gain/loss) Yes No Chest/Heart (Ex. Chest pain/Palpitations) Yes No Neurological (Ex. Memory Changes,Difficulty Walking, Slurred Speech) Yes No Genitourinary (Ex. Urinary frequency, Burning with urination, Sexual function problems) Yes No Throat (Ex. Sore Throat) Yes No Head/Neck (Ex. Neck pain, Headaches) Yes No Back (Ex. Low Back Pain) Yes No Endocrine (Ex. Excessive thirst, Cold/heat intolerance) Yes No Gastrointestinal (Ex. Abdominal pain,Nausea/vomiting, Rectal bleeding) Yes No Hematological (Ex. Easy brusing, Easy bleeding, Lymph node swelling) Yes No Psychiatric (Ex. Depression, Anxiety, Psychosis) Yes No Lungs (Ex. Cough, Shortness of breath) Yes No Ears/Nose (Ex. Hearing loss, Ringing, Nose bleeding) Yes No Mental Health: Is stress a major problem for you? Yes No Do you feel depressed ? Yes No Do you have trouble sleeping? Yes No Social History Exercise Sedentary (No exercise) Mild exercise (walking, etc) Regular vigorous exercise (4x/week) Alcohol Drink alcohol ? How many drinks per week ? No. of Drinks per week Tobacco/ Smoking Use tobacco Smoke Quit Smoke ? No. of Drinks per week (copy) Send Details
