Consultation Format




Patient Medical History


Patient Name
*
Prefix

First
*
Last
*
Suffix

Birth Date


MM
/
DD
/
YYYY
Age
*
Gender
*
Describe briefly your present symptoms:
*
Please list the names of other practitioners you have seen for this problem:



Any Major Hospitalizations (include where, when, & for what reason):
*


CURRENT MEDICATIONS

Drug allergies:

 Yes 
 No 
To what?



Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:
Name of drug

1.

2.

3.

4.

5.

Dosage

1.

2.

3.

4.

5.


PAST MEDICAL HISTORY

Do you now or have you ever had:
*
 Diabetes 
 Heart murmur 
 Crohn’s disease 
 High blood pressure 
 Pneumonia 
 Colitis 
 High cholesterol 
 Pulmonary embolism 
 Anemia 
 Hypothyroidism 
 Asthma 
 Jaundice 
 Goiter 
 Emphysema 
 Hepatitis 
 Cancer 
 Stroke 
 Stomach/Peptic ulcer 
 Leukemia 
 Epilepsy (seizures 
 Rheumatic fever 
 Psoriasis 
 Cataracts 
 Tuberculosis 
 Angina 
 Kidney disease 
 HIV/AIDS 
 Heart problems 
 Kidney stones 
 Other... 
Please specify


PERSONAL HISTORY

Were there problems with your birth?

 Yes 
 No 
Please specify

Medical File Upload

Medical File Upload


Purpose of Contacting Dr.Bhat's Marma Chikitsa

Please check the appropriate box(es).
*
 Inquiry 
 Consultation 
 Medicines 
  Marma Chikitsa 
  Appointment 


To revert back please provide your contact details.

Email
*
Phone
*
Whats App / Telegram App No

Address
*
Street Address
*
Address Line 2

City
*
State / Province / Region
*
Postal / Zip Code
*
Country
*



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