FOR DOCTOR'S USE ONLY

Name:
Age:
Gender: Male / Female

Hypertension/Diabetes Mellitus-T1 or T2/Hypothyroid/Hyperthyroid/

Pre existing Medical Cholesterolemia/Fatty liver/Benign Prostate hyperplasia/PCOS/PCOD
conditions:

Present/chief Complaints:

History of Present complaints:

Past History: Hysterectomy/LSCS/Appendectomy/cholecystectomy/Cholecystitis/Cholelithiasis

Renal calculi/Pacemaker/ Heart valve replacement/Typhoid/Jaundice/Malaria/Influenza
Pneumonia/Gout/Skin disease/Worms/Hernia-Umblical/Inguinal/Hiatal

Allergies:
Family History:
Father
Mother
Menstrual History: Regular/Irregular/Dysmenorrhea/Leucorrhoea/
Personal History: Digestion: Poor/Good Belching or Eructation/Burning/Acidity/Acid reflux
Bowels: Regular/constipated/loose stools/Flatulance/Steatorrhea
Appetite: Thirst:
Micturation:
Sleep: Sound/interrupted/Distrubed/Insomnia/Increased/Refresh/Does not refresh

Addictions:
Milk tea:
Milk Coffee:
Smoking:
Alcohol:
Beetle/Pan chewing:
Vitals:
Blood pressure: Pulse Rate:
Respiratory Rate: Herat Rate:
Temperature: SpO 2 %:
General examination: Apperance/Built:
Anemic pallor: Yes/No Lymphadenopathy: Yes/No Icterus:
Oedema: Varicose vein: Yes/No- Right/Left
Nails: Cynosis/Koilonychia/Psoriasis pitting/clubbing/onycholysis/leuconychia

Systemic Examination:
RS

CVS

CNS

GIT

MS

Investigation Report:
Medicine/Drug History:

Provisional Diagnosis:

Primary Health Goals:

I hereby abide by the terms and conditions for admission and treatment at the
hospital. I am joining this hospital on my own interest and the institution will not
be responsible for any damage, injury or complications whatever from the
treatment during my stay here.

Date of admission:

Signature of the patient Signature of CMO/MO

 ANTHROPOMETRY & Whole body composition analysis
Name:
Age:
D.O.A:- D.O.D:-
Ge ne ra l Ge ne r a l
He ight
We ight
Fa t
Body a ge
BMI
Kilo Ca lorie
V.Fa t
S.Fa t
Mus cle

Arm s Arm s
S.Fa t
Mus cle

Trunk Trunk
S.Fa t

Mus cle

Le gs Le gs
S.Fa t

Mus cle

Date: BP: FBS: RBS: PR:

Remarks:

Add Treatment Morning/Noon Therapy Morning/Noon Therapy Physio Yoga & Kriya
Morning Bamboo M Acupressure Cir Jet GH Pack Kidpk OGG pack PLB US- Vamanakriya
Mpk-Abd/Eye Abhy DTM WGP HKW COPK F.WSP SGC Pack SWD- LSP
Comp-Abd/sp HSM SWDM Kanji Rice B/L Pack Chromo.T Magnet IFT Jalaneti
Enema-Neem/Neu S.Glow M Shiro Pichu A.Nasyam Pedi Jet NJHB Shiro/Takra Wax bath Sutra neti
Colon Hydro Elakizhi CPS(Podikizhi) Delux Hydro - N H C Dry Head M IR lamp Eye wash
LSP MLD Thai massage Spinal Spray/Bath- N H C Imme- Min/Her/Sa EMS Special Yoga TPY
Vamana kriya Udhwar Pizhichil Saunabath Facial steam Netra Tarp Foot vibrator
Shir-Dara Sharvanga D Pack-Leg/knee/Ankle/spin/throat/ Shoulder-whe/Pul
Noon
Takra-Dara Ne-alo-Tur Mud- Full body/Face/spin/Knee/ WPB Shoulder ladder
Mpk-Abd/Eye Vasti-Janu/Kati/Greva/uro Facial- Fruit/herba/oats FGPK Hair Pack Exercise ball
Comp-Abd/sp HFAB Bath- Hip/arm/foot/ arm&foot N H C Gym
Detox Sauna PM- Vasti-Janu/Kati/Greva/uro Acupuncture
IR sauna Vibro M- Ozone- Face/Head/Leg/Full/ BOTO
Steam Bath Local steam Beauty Care - Mustard Pack- Reflexology- H / F
Special Instruction: