PRESENTATION OF DATA FOR AYURVEDIC HEALTH ANALYSIS BY DOCTORS’ 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:-

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     Male Female   Select One 123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120 Select One Single Married   Select One 12345678910   Select One 5051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200   Select One 123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260261262263264265266267268269270271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300     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