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PERSONAL INFORMATION 
Specilality Medicine Kaya Chikitsa (General Medicine in Ayurveda)
Name  
Age     Sex        
EMail Address
Address
Occupation
Marital Status    
Complaints with History
Treatment History
  
PERSONAL HISTORY 
Nature of Work and Exercise
Exposure to Occupational Hazards
Habits  
Diet    
Sleep
Allergies
Addiction
MENSTRUAL HISTORY 
Menarche
LMP
Dismenorroea
Pregnancy 
Still Birth/Abortion
GENERAL HISTORY 
Height & Weight  kg
Pulse Rate
Blood Pressure
Temperature
State of Nutrition
General Appearance
LABORATORY INVESTIGATION  
Blood
Urine
Special Investigations
Security Code