MaritalStatus: MarriedSingle

Dependence on: AlcoholDrugsSmokingCoffee/TeaOther Substances/Medication

Any Past History: Hypertension (high B.P.)DiabetesAllergySurgeryOthers

Planning for Pregnancy in next 6 Months: YesNo

Duration of the complaint:


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Gender: MaleFemale

Are you a Vegetarian: YesNO

Functional history: AppetiteAcidityGasMotionUrination – day/nightSleep – day/nightDiet - veg/non vegLifestyle – daily general routineOthers

Blood group:

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