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Age *

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Weight *

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Structure

• Obese
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Present complaints with full history

Hereditary factor: Has the patient or his/her near relatives had such complaint ? if so, furnish details in brief.

Any cause known to you for the disease

Any history of venereal disease, malaria, filaria or any other noticeable ailments.

State of Appetite, Digestion, Motion, Urine, Sleep.

Dietary habits

Vegetarian or non vegetarian food articles being taken and their timings.

Addiction to smoking, alcohol, etc.

Nature of Work

Number of issues/kids

Menstruation, delivery, etc, problem if any (for women).

Climate & present weather conditions of the place where you live. Any problem of pollution of air, water, etc.

Treatment done so far

Details of Investigation / Medical Reports.

Any Known Allergies

Blood pressure

Other information, if any

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