Chronic Form

Name :
E-Mail :
Marital States*	[ Married ] [ Single ]
Occupation *
Address *
Contact No *
Chief Complaint *
Past Disease History if any *
Family History if any*
which weather you like *	[ Hot ] [ Cold ]
Are You Feeling Thirsty *	[ Yes ] [ No ]
Appetite *	[ Normal ] [ Medium ] [ Disturbed ]
What do you like in eating *
What about you sleep *	[ Good ] [ Disturbed ]
Bowel Movement *	[ Loose ] [ Normal ] [ Constipated ]
Have you feel or undergone any mental or Physical stress Please explain in detail *
Personal Observation about Your anger
Personal Observation about Your studies
Personal Observation About your studies