* Name :
* Address :

* Postcode :
* Tel. No. :
* Present Problem :

* G.P's Diagnosis & Treatment :


* Daily Food & Drink :

* Pulse :
   Vata:
   Pitta:
   Kapha:

* Blood Pressure :

* Diat Advice :
   Pathya :                                                                        Apathya (Avoid) :

 
* Ayurvedic Diagnosis:

* Ayurvedic Treatment :


* Family Medical History :

* Previous Operation :

* Allergy History :

* Stool - Constipation :                                                Loose Motion :

* Urin :
* Sleep :
* Any Other Problems :


* Ayurvedic Dr's Opinion About Your Problem :