DR. PRASANNA M. KELKAR
Patient's Profile Form
I.
GENERAL
Name of Patient:-
Age:
1
2
3
4
5
6
7
8
9
10
11
12
13
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16
17
18
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20
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83
84
85
86
87
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90
91
92
93
94
95
96
97
98
99
100
M/F:
M
F
Weight:
kg
Height:
ft/inch
Address:
Email Address:
II.
SPECIFIC
1) Nature of Stools (quantity/ colour/smell etc.):
2) Nature of urine (quantity/ colour/smell etc.):
3) Color of eyes:
4) Colour and nature of Tongue:
Coated
White
Red
Extra Wet
Dry
Normal
Uncoated
5) Skin(texture/ colour/ dry etc.):
6) Appetite( heavy/ medium/ light):
Heavy
Medium
Light
No Apetite
7) Sleep pattern :
Sound
Disturbed
With Dreams
III.
DIET (Total daily intake in detail with approx. timing)
IV.
EXERCISE ( Daily exercise- nature, quantity and time)
V.
Present Symptoms
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