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Personal information
Select Any One
Male
Female
Third Gender
Select Any One
Single
Married
Seprated
Medical Information
Select Any One(Mode of Onset)
Sudden/Gradual
How did the problem start
How has it progressed
Selcet Any One[Past History,please specify the detail of following(if any)]
Any Medication
Hospitilization
Surgrey
Accident
Select Any One[Family history/Personal history of any of the following]
Diabetes
Hypertension/High Blood Pressure
T.B/Cancer
Memory Loss
Flatulence/Acidity
Any Other
Past Treatment Information
Selcet Any One[Life-style of the patient (before and after the diagnosis)]
Dietary habits-Smoking/Non-veg./Alcohol/Tobacco/Any other/Not applicable
Hypertension/High Blood Pressure
Physical activity – Any workout (please specify)
Mental activity
Social interactions
Any Other
Select Any One(Body Built)
Thin
Medium
Well built
Select Any One(Complexion)
Fair
Dusky
Dark
Select Any One(Skin Nature)
Dry
Oily
Normal
Select Any One(Nature of Hair)
Dry/Rough
Oily/Silky
Thick
Thin
Premature graying/balding
Select Any One(Joint characteristics)
Emits sound
Hot to touch
Soft and flabby
Select Any One(Appearance of veins and tendons)
Prominent
Normal
Not prominent
Select Any One(Patient's body is)
Cold to touch/lowered temperature
Hot to touch/raised temperature
Normal
Select Any One(Temperature preferences)
Cannot tolerate cold
Cannot tolerate heat
Can tolerate both
Select Any One(Eye)
Dry
Reddish/Pale
Moist
Select Any One(Nature of teeth and gums)
Talkative
Talkative
Measured conversation
Select Any One(Appetite)
Irregular
Robust/Cannot tolerate hunger
Low appetite
Normal
Select Any One(Preference for taste)
Sour
Sweet
Salty/Spicy
Select Any One(Sweating)
Scanty
Profuse
No sweating
Any Other
Select Any One(Excretory habits)
Constipated/hard/dry stool
Loose stool
Well formed/Normal
Select Any One(Urination)
Painful/Scanty
Burning/Hot
Frequent/Profuse
Normal
Select Any One(Sleep)
Disturbed sleep/Insomnia
Moderate
Sound sleep
Select Any One(Psychological status)
Restless
Irritable
Stable
Select Any One(Memory)
Forgetful
Moderate
Sound
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