DR.  PRASANNA   M.  KELKAR

  PATIENT'S PROFILE   FORM

I. GENERAL

 

Name of Patient:-


Age:-          M/ F :-         Weight.:-  Kg      Height:-  ft/inch

Address :-

E- Mail Address :-

II. SPECIFIC 

1) Nature of Stools (quantity / colour / smell etc.) :- 

  2) Nature of urine (quantity/ colour/smell etc.) :- 

 3) Colour of eyes :-

  4) Colour and nature of Tongue :-

  5) Skin(texture/ colour/ dry etc.) :-

  6) Appetite( heavy/ medium/ less) :-

  7) Sleep pattern :-

  III. DIET  (Total daily intake in detail with approx. timing) :-

IV. EXERCISE ( Daily exercise- nature, quantity and time ) :-

  V. Present Symptoms:-                        

                

                                      

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