vaidyagrama

prefix

first name

last name

gender

male
female

age

email address

city, country

current medical problems

current medication (if any)

past medical problems (if any)

past medication (if any)

surgical history (if any)

reproductive history (if any)

habits (if any)

diet

exercise

sleep pattern

emotional state

laboratory investigations

intended date of arrival (dd/mm/yyyy)

intended duration of stay (no. of days)

any other information