Name Address Country Tel Fax Email ID Age Sex Male Female Height  cms Weight  kg Nature of Job Any problem with your eye sight? yes no How is your appetite? Do you have constipation regularly? yes no Any  physical problems you have? How many year you are suffering from Diabetes? or cervical spinal problems? Do you have Blood Pressure?  Normal Low High Did you consume liquor? Yes      No Did your fore fathers or parents have diabetes?(For diabetic patient only) Yes      No Your latest blood and urine sugar reports?(For diabetic patient only) Your present medication details? Kindly send us any other health problems if you have