* Compulsory fields. * Name : * Age : * Sex : Male      Female * E-mail : *Tel No. : Mailing Address : Disease Diagnosis : Pulse/minute : B.P. : Height in Meters : Weight : Main Problems with Duration : (Brief Description) Investigations/Recent reports done : Medicine/treatments taking : Physical Status : Feeling of fatigue No at all Only on over exertion In routine work Even after Rest Psychological Status : Mental disturbance by personal-working problems No even I can counsel others Yes but can calm easily myself I need others help to settle I need medicine to settle down Immune-status: Illness Never Rarerly Due to change in weather-diet-place Frequently &take time to recover         with proper medicines Digestive-metabolic-status: Good diet & proper timely appetite Moderate diet& regular appetite Moderate diet but delayed\low         appetite Less diet &regularly no or low         feeling of appetite