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QUALITY OF LIFE MANAGEMENT CONSULTANCY
Case Record Form
Registration Details
*
Registered at (Centre):
Date of Regn:
Personal Details
Please provide as much information and detail as possible
*
Title
*
Name
*
Gender
Male
Female
*
Age
Contact Details
  Postal Address
Home Telephone
Mobile Telephone
*
Email Address
General Details
Major complaints, since when:
Other complaints, since when:
Family H/O any major disease:
Habits or addictions, since when:
H/O major health problems (like hypertension, diabetes, asthma or any surgery):
Obstetric and gynecologic data (
for women
):
Vital information:
Pulse :
Temp :
BP :
Others :
Bowel Habbits:
more than once a day
once a day
once in 2 days
still longer
If Others Please Specify
Urine:
Normal
More
Burning
Difficulty in urination
If Others Please Specify
Other feature/s of ill health (Based on observation / evaluation / interrogation):
Impression/Diagnosis:
Prakruti:
V
P
K
Vp
Vk
Pk
Pv
Kv
Kp
Bal.
Check Your Prakruti