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Ayurvedic Health Analysis
   
 

PRESENTATION OF DATA FOR AYURVEDIC HEALTH ANALYSIS BY DOCTORSí PANEL

Dear Sir / Madam,

READ this carefully once and then fill out. All information is kept strictly confidential.

Please attach additional information including medical reports if relevant:-

 

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  Guest’s Input  
 
Name
Gender
Age
Day time phone number
Mobile
Occupation
Marital status
Number of children with their age
Height in cms /feet inches
Weight in stone/ kilos
Time period you can stay in an Ayurvedic
retreat (give dates if possible)
Main aim in visiting an Ayurvedic retreat
Visiting alone or with company
 
 
Chief Complaints
 

 
 
 
 
 
 
 
Duration
 
 
  History of Disease  
Duration
  Heart Disease  
  Hypertension  
  Hypercholestrimia  
  Joint diseases  
  Stomach complaints  
  Respiratory disease  
  Liver disease  
  Skin allergy / disease  
  Hay Fever / Sinusitis  
  Eye disease  
  Ear disease  
  Hemorrhoids  
  Renal (kidney) diseases  
  Sexual weakness  
  Epilepsy  
  Giddiness  
  Swelling  
  Thyroid problems  
  Urinary disease  
  Injuries  
  Headache  
  Uterine fibroid  
  Ovarian cyst  
  Intestinal disease  
  Numbness  
  Gas accumulation  
  Any other previous illness  
  Are you currently taking any medication? If yes, give details.  
  Food items you are allergic to and reaction  
  Food items you avoid and why  
       
  Do you usually / occasionally /frequently get bloating / gas / cramps after eating / when you don’t eat properly / even when you eat properly? OR
Other important symptoms you have noticed related to your digestion are:
 
  Recent Blood Test Results:Date of test    
  Hb  
  TWBC  
  Polymorph  
  Lymphocyte  
  Eosinophils  
  ESR  
  Blood Sugar FBS  
  Blood sugar PPBS  
  S. Cholesterol  
  SGOT (AST)  
  SGPT (ALT)  
  Lipids Profile  
  Triglycerides  
  Total Cholesterol  
  HDL  
  LDL  
  VLDL  
       
 
Please Attach a file  
     
   
       
     
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