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KANNAMPARAMBIL

ayurveda clinic

A Traditional Approach For All Ailments

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Name
Age	Male Female Other
Address
Pin Code
Contact Number
E-mail
Occupation
Presenting Complaint
Are You Feeling Any Systemic Disaease? Eg: Diabetes, Blood Pressure etc..	Yes No
Your Parent / Guardian is suffering the same complaint?	Yes No
Do you had any surgery / treatment?	Yes No
Bowel
Appetite

Approximate hour of sleeping?
Body Weight (Kg)
Body Constitution
Menstrual Cycle
Body Mass Index (BMI)
Blood Pressure
Smoking	Yes No
No. of cigarette / day
Drinking	Yes No
No of Drinks in a week
Appointment Date

I here by declare that the details furnished above are true to the best of my knowledge and belief