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  Patient Registration Form :
 
Name : * Date of Birth :
*
Time of Birth : * Place of Birth : *
Sex :
Male Female
Address :
E-Mail ID : * Phone :
Mobile : * How you wish to contact :
Occupation/ profession : Marital Status :
Married Unmarried
Any family history of obesity or any other disorder
:

Heredity

:
Maternal Paternal
Habits
:
Smoking drugs
Alcohol Tea
Number of family members
:
Requirement of oil + Ghee / month in family
:
Requirement of Sugar /month in family
:
Eating Habits :
Vegetarian  
Non – vegetarian  
Consumption of out side food /week :
Habit of taking :
Milk Soft Drinks
Fruits Dry Fruits
Chocolates Honey
Coconut Water
Dietary regime :
Daily routine :

Amount of water consumption/day

:

Exercise if any

:
Yoga Pranayam
Use of oral contraceptive in females :
Yes No
Menstruation :
Regular Irregular
Unwanted hair growth on face or elsewhere in the body :
Yes No
History of any past disease :

If yes, any medication on

:
Main complaints :

Weight in kgs

:
Height in cms : Abdominal girth in lying down position in cms :
Hip circumference : Routine BP readings :
Frame of body : Area where more fat is deposited :
Feeling of lethargy : Breathlessness :
Yes No
Feeling of puffiness over the body : Feeling of numbness :
Yes No

Breathlessness in resting position

:
Yes No
Sweating :
Mild Excess
Hunger : Mental irritation :
Any other specific problem :

Hairfall

:

Standing Photo of patient

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