Case Sheet

If you wish to consult us, please fill the following case sheet as completely as possible. You can contact us either by mobile phone (9848524475, 9848735889), or on skype name (lakshmanrao1) after you email the filled case sheet. 

CASE SHEET

GENERAL BACKGROUND

Family name

Given name

Date of birth

Sex

Martial status

Number of children

Profession/occupation

Residential address

Residential phone

Mobile phone

Present ailment

Previous ailment

FOOD PREFERANCES

Vegetarian or non-vegetaian ?

If vegetarian frequency per week?

Do you eat out?

How frequently?

Do you smoke?

How many times per day?

BEVERAGES

Coffee,how many times per day?

Tea,how many times per day?

Soft drinks,how many per day?

Wine,how many glassess a day?

Alcohal, how many pegs a day?

EXERCISE HABITS

Do you exercise ?

How frequently in a week?

Duration of exercise in minute in each session ?

FEMALE PATIENTS

Menses cycle in day ?

Menses flow in days ?

Pre-menstrual tension ?

Back pain ?

Headache,migraine headache ?

MALE PATIENTS

Mental stress in a family environment?

Mental stress in a work environment ?

Energy level

GENERAL INFORMATION

Height

Weight

Pulse beat per minute ?

Chest extension in cms ?

BOWEL MOVEMENT

Appetite ?

Acidity ?

Flatulance ?

Belchings ?

Constipation ?

Micturation ?

Previous test reports ?

Treatment already taken ?

CONSENT FOR TREATMENT

I have voluntarily given my complete health history. I voluntarily authorized the Australian Herbal Clinic to provide treatment that it regards as appropriate. I do not hold the doctor or the Australian Herbal Clinic as responsible for any unforeseen effects of the treatment.

 E-mailing this case sheet is regarded as full consent of the patient. {g_l_rao@aitkin-australia.com}