| * Required Fields |
|
| | |
| Form No |
T-26 |
| Disease/Disorder : |
Colour Blindness
|
| * Name : |
|
| Gender : |
Male
Female
|
|
Father
Husband
Guardian Name :
|
|
| Address : |
|
| City / Town : |
|
| State : |
|
| Country |
|
| E-mail : |
|
| * Contact No.: |
|
| Occupation: |
|
| DOB : |
|
| Age: |
|
| Weight : |
|
| Disease/Complaints/Pain/Problem : |
|
| Sleep : |
Disturbed
Sound
With Dreams
|
| Urine in day : |
( times ) |
| Pain: |
before
during
after
|
| Urine in night : |
( times ) |
| Pain: |
before
during
after
|
| Stool/Feces : |
Normal
Constipation
Hard
Loose
|
| Hunger : |
|
| Thirst : |
Normal
More
Less
|
| Taste : |
Sour
Sweet
Salty
|
| Menstrual Cycle : |
Clots
Scanty
Excess
Normal |
| Attitude : |
Grumpy
Sprightly
Concerned
Depressed
Fearful
|
| Habit : |
|
| Past/Family History : |
|
| Pathology : |
|
| B.P. : |
|
| Clinical Examination/Investigation Report : |
|
| Other Report : |
|
| Diagnosist : |
|
| Treatment undergoing at present : |
|
| * Mode of Payment for Subscription : |
Payment Options
|
|
I myself come for treatment on my own responsibility. Doctors & Institute are not responsible for any cause.
|
* Enter code shown in image |
 |
|
|
300
