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Id:123456

Name:

Phone:

Gender:

Age:

Father's Name:

profiession:

Marital Status:

Physical Structure:

1. Present Problem:

2. Modalities(Aggravation):

3. Modalities(Amelioration):

4. Past Disease History:

5. Family history:

6. Langushment:

7. Perspiration:

8. Perspiration:

9. Bath:

10. Tongue:

11. Thirst:

12. Appetite:

13. Desire food:

14. Aversion Food:

15. Stool:

16. Urine:

17. Sleep:

18. Salivation:

19. Fear:

20. Diabetes Status:

21. Blood Pressure Status:

22. Favorite color:

23. Dislike Color:

24. Clinical Diagnosis Report:

25. Other Symptoms:

26. Mentality Symptoms:

Date	Remedy	Power	Quantity	Prescribed By	Commnets
22-oct-2022				Dr. Aman Ph:019283-79273

5

15

20

40

chember name:
zamzam homeo hall

Id:123456

Choose Skin

General Settings

5

15

20

40

chember name: zamzam homeo hall

Id:123456

Choose Skin

General Settings

chember name:
zamzam homeo hall