| *  Required Fields  | 
				   | 
			
			 |   |    | 
			
				|  Form No  | 
				 T-26 | 
				
			
			
			
				| Disease/Disorder :  | 
				
				Cold  
				
				 | 
			
			
				| * 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  | 
				  | 
			
			
						
						
						
			
				| 
				
				 |