First Name                Last Name

Age

[Select] Tea Coffee Drinks Tobacco Smoking Narcotics

[Select] Married UnMarried Divorce

[Select] Sedentary Mental Hard Work

[Select] Worried Irritated Relaxed

Normal Disturbed Insomnia

[Select] Veg Non-Veg Veg & Non-Veg [Select] Eat according to time Eat according to hunger Eat according to appetite

[Select] Less then 5 glass 5 to 10 glass 10 to 15 glass more than 15 glass

[Select] Once a day Twise a day Once in 2 or 3 days more than 2 times a day

[Select] Hard Soft Loose Sticky

Other:

Normal Red Yellow

[Select] Heavy Moderate Scanty Not Applicable                 [Select] Delayed Regular Early (optional)

Other: