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:  
    If Others Please Specify 
  Urine:  
    If Others Please Specify 
  Other feature/s of ill health (Based on observation / evaluation / interrogation):
  Impression/Diagnosis:
  Prakruti:   Check Your Prakruti