DETAIL INQUIRY Ref By: Name: Age (years / months) Gender: Select Gender Male Female Child Infant PARENTS NAME (IF MINOR): Address : City:  State: Country:  Zip: Telephone / Fax / Mobile : E-Mail: Present Complaint with Duration : History of Complaint : Diet: Select Diet Veg Non-Veg Mixed Habits: Select None Smoking Smoking + Tobacco-chew Smoking + Tobacco-chew+ Drugs Alcohol: Select None Alcohol Occasion Nature of Work : Select None Active Sedentry Previous Treatment : (Duration, Type-Ayurvedic/Allopathic/Homeopathic, Details, Side Effects if any.) Treatment Results : Select None Positive Normal Negative Medicines Consumed : Medical Reports :

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