Prakruti ayurvedic health resort, Satara Date __/__ /____ Name………………………………………………………………………Date of birth __/__ /____Gender…..…… Age….. years Address…………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………….... ……………………………………………………………………………………………………………………………………………………………….... Pin code ______ Residential number_____- ________ Mobile number___________ email id………………………………………………………………………………………. Educational qualifications…………………………………………………………………………….Weight…… kgs. Height ……….. Occupation……………………………………………………………………………………………………………………………………………….. Professional title……………………………………………………………………………………………………………………………………….. Detailed note on health issues of the patient………………………………………………Since when?........................... .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. Do you have a medical history any of the following? Family’s medical history Measles / chicken / small pox / typhoid/ jaundice……………………… blood pressure / diabetes/ vitiligo / ........................................................................................................eczema /heartdiseases /cancer/ Dysentery/ worms/ conjunctivitis/ otitis media/ herpes ................ respiratory diseases/asthama pneumonia/ fracture/ skin diseases/ gastro ……………………………….Maternal family-mother /maternal ……………………………………………………………………………………………….…. uncle/ grandmother/ grandfather/aunt heart diseases/ kidney stone/ urticarial ………………………………………………………………………………………………….. Paternal family– father/ paternal …………………………………………………………………………………………………...uncle/grandmother /grandfather /aunt Routine related: Morning breakfast-.........................................ExerciseWork form- sitting/ intellectual/ stressful/ mental pressure Food related: Good appetite/ poor appetite/ because it is timeVegetarian/ Non-veg…………………………………….Food preferences: Sweet/ spicy Favorite food- Toilet related- Daily: Yes/ No….State: Solid..Smooth..Inconsistent..Lose..Sticky Other complaints– Urine related- Frequency in a day……….. Urine color: Transparent..Yellowish..Reddish..Turbid Burning sensation: Yes/ No Other complaints– Problems related to men's health– Problems related to women's health– Menstrual problems– Sleep related- deep sleep/ insomnia/ startled awake/ disturbed sleep………….Sleep during the day– Other complaints- Addictions (if any)– Nature related: Sensitive/ Aggressive/ Both.Other: Angry/ Heart palpitation/ Scared/ Lack of enthusiasm Were you ever mentally disturbed? Yes/ No