Patient data:    Date…………...  Case no…..…..  Place ……………….  Sr. No…….

Patient name…………………………………………………………………………...

Address. ……………………………………………………………………………………

Telephone no. …………………………  Mobile……………………………………..…

Sex                    Male / Female      Birth date ………………………  Age……….

Height. ……………  C.m. / Inch          Weight……………………..K.G. / Pound

Present physical problem
1,………………….…………………..…  2, ………………………………………………….

Present psychological problem
1,………………….…………………..…  2, ………………………………………………….

Present emotional problem
1,………………….…………………..…  2, ………………………………………………….

Past health history……………………………………………………………….…………..

Family health history…………………………………………………………………….…..

Treatment from family doctor………………………………………………………………

Present medicine.………………………………………………………..…………………..

Hospital treatment / operation…………………………………………….……………….

Therapy tried …………….……………………………………………………………………

Life style
Liquid intake per day……..…Litre

Food:  Vegetarian / Non vegetarian / both

Food in breakfast:…………………………………………………………………………..

Food in lunch ……………………………………………………….………………………

Food in evening………………………………………………….………………………….

Food in dinner……………..…………………………………….……………………………

Other food / liquid in take…………………….…………………………………………..

Food proportion

Breakfast………….……………….%                Lunch…………………..…….……….. %
Evening food ……..………………%                Dinner………………………….……….%

Habits daily and other information
Tea…….…………………………..…,                      Coffee………………………..……….…..,
Soft drinks……………………………,                   Cigarettes / Tobacco ….…….……….…,
Alcohol peg …….…………………...,                  Drugs…..……………………...…..………,
T.V. Hours……………….…………..,                   Night sleep hours…………..……………,
Day sleep hours…..…..…...………..,             Walking miles / day.………..……………,
Other………………………………….,                    Blood pressure high…….……….…Y / N,
Blood pressure law…………….Y / N,            Heart beat…………..…….…..…./ minute
Married………………………….Y / N,                  Living with family…….……………..Y / N,
Working ………………………. Y / N,                 Hours / day ………………………………,
Exercise…………………………Y / N,                  Type…..….……………….……………….,

Do you have?
Headache              Y / N,                                        Constipation                              Y / N,
Skin problem         Y / N,                                        Proper hunger                            Y / N,
Proper sleep           Y / N,                                       Happy sex life                            Y / N,
Depression           Y / N,                                         Negative thoughts                       Y / N,
Worries           Y / N,                                              Energy deficiency                        Y / N,
Joints problem           Y / N,                                    High cholesterol                           Y / N,
Diabetesnbsp;          Y / N,                                    Heart problem                             Y / N,
Tried yog;          Y / N,                                            Tried herbal medicine [ayurved]   Y / N,

Other information……………………….……………………………………..………………

Healer’s diagnosis…………………………………………………………………………
                            …………………………………….……………………………………

Nature of body    Cough / Pitt – Acidity / Gas

Therapy suggested / given Dt.…………..  As……………..……………..…..……..
Dt..………………  As…………………………………………………………………..….……
Dt ……………….  As……………………………………………………………………..……

Life style suggested ………………………….……………………………….…………

Note
  1. Filling information in above form is voluntary.
  2. Please continue your present medicines.
  3. Keep in touch with your present doctor about alternative therapy treatment given to you.
  4. This treatment is for average healthy patient for serious or critical illness, doctors should be consulted for use of alternative therapy.
  5. Information given by patient and treatment given will remain confidential.
  6. I am adult, I have given and understood above information. I have been explained about therapy and
    I willingly accept to take alternative therapies at my responsibility.
…………………………
Signature of patient