Health Questionnaire

Name
S/o, W/o
Work Address
FAX
Age
Weight
Veg: Non-veg:
Smoking	YesNo
Alcohol	YesNo
Details of disease:
Food habits till date:
Morning:
Noon:
Evening:
Night:
Methods of treatment taken:
I would like to take your advice and live healthy free of diseases. Yours P.S: Your comments and opinions on the stage after disease is cured.