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Name
Full Name
*
Address
*
Mobile No
*
Email
*
Age
*
Sex
*
Male
Female
Weight (Kg)
*
Height
*
Hair
Short
Bald / Light
Dark
Color
Grey
Brown / Premature Grey
Black
Look
Curly
Curly-Straight
Straight
Dry / Oily
Dry / Rough
Soft / Oily
Very soft / Very oily
Growth
Slow
Normal
Fast
Overall
Thin, Spilt hair
Normal
Thick / Dense
Teeth
Crooked
Normal / Even
Large / Even
Nails
Brittle / Straight lining
Soft / Without lining
Hard / Thick /Pinkish
Skin Temperature
Cold
Slightly Warm
Normal
Skin look
Dry/ Rough/ Wrinkled
Mole / Freckles
Soft / Smooth / Stain free
Where are fat deposits
Around waist
Evenly distributed
Around thighs and hips
Sleep
Disturbed / Light
Normal / Short
Long / Deep/ Any time
Appetite
Irregular
Strong
Regular
How many time you eat?
Irregular
4 time (with breakfast)
2-3 time (with breakfast)
Which food you like?
Changeable
Sour, Spicy food
Sweet, Chocolate, Heavy food
Stool
Dry, Painful
Normal
Soft, Sometimes sticky
How many time?
less>1 time in a day, irregular
1-2 time, regular
more<2 time
Urine
Little
Sometimes Burning
Normal
How many time?
less>7-8 time
7-8 time
more<8 time
Sweat
Sometimes
Excessive, foul sometime
Normal
Work style
Rapid
Technical, Aggressive, Logical
Slowly
Memory
Fast to grasp, but not for a long time
Normal
Slow to grasp but long-term memory
Would you like?
ravel, Art like often changes in life
Spots, Politics, Fashion, Jewellery, Cloth, Perfume, Movies and parties
Business, Quite place, Yoga, Don't like fast changes in life fast
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)
