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Counseling Form

Full Name

Address

Mobile No

Age

Sex

Weight (Kg)

Height

Hair

Color

Look

Dry / Oily

Growth

Overall

Teeth

Nails

Skin Temperature

Skin look

Where are fat deposits

Sleep

Appetite

How many time you eat?

Which food you like?

Stool

How many time?

Urine

How many time?

Sweat

Work style

Memory

Would you like?

Present Complain with Duration

Other Complain

Are You on Medication? If yes, for which condition? (Please Described only the name of complains - not necessary to write the name of medicine)

If any disease described below have your family members please mention

High B.P., Low B.P., Asthma, Diabetes,Thyroid, Heart Disease, Tuberculosis, Skin Disease or any other

Details of Hospitalization (Reason, month / year of incident)