CONSULTATION

      
 

 
   
           
 
   

Here we provide a facility to you, to seek remedies for your problems. Kindly fill the following details carefully, which may help us to understand your problem and hence can suggest a good treatment to you.
Our Chief Physician Ashtavaidyan Alathiyoor Narayanan Nambi will suggest the treatments for your good health.

    
 
         
         
     
Name of the patient  

Guardian’s Name (In case of a minor)

  
Organization  
Street Address  
City  
State  
Country  
Postal code  
Telephone  
Fax  
E-mail ID  
Alternate e-mail ID  
Age  
Sex  
Height  
Weight  

Structure(Obese/Medium/Lean)

  

JOB DETAILS

 Nature of work and whether it involves traveling
 

PRESENT COMPLAINTS
List of present complaints with duration of each
SNo

DESCRIPTION

DURATION
1.

2.
3.
4.
5.
6.
 
Full History of present complaints:
Details of investigations done so far:
Upload your investigations and other data:

Current Medication:

Allergies:
History of previous illnesses:

Past Medical History
DISEASES    
HYPER TENSION YES NO
DIABETES YES NO
FILERIA YES NO
JAUNDICE YES NO
PILES YES NO
FISTULA YES NO
ULCER YES NO
ANEAMIC YES NO
OTHERS
   

 
Inpatient Treatment Required YES NO
 

STATE OF DIGESTION
   
APPETITE
BOWEL HABITS

URINE QUANTITY
APPETITE
 

MENSTRUATION
   
CYCLE
FLOW
ASSOCIATED WITH
MARITAL STATUS
 

Delivery: Problems if any
 
DIETARY HABITS
  Vegetarian
Mixed
SCHEDULE

MENU

TIMINGS
EARLY MORNING
BREAK FAST
MID MORNING
LUNCH
EVENING
NIGHT

ADDICTIONS IF ANY

Smoking / Alcohol / Tobacco chewing
 
 

Others please specify:

 

  
   
 

Copyright © 2007 S.N.A. Oushadhasala PVT LTD, All Rights Reserved

 
 

Thrissur- 680 005, Kerala, India, Tel: (91-487) - 2420948, 2441947, Fax: (91-487) - 2441948

 
 

Email: mail@thaikatmooss.com