Fields marked with * are required.
Age in Years *
Name of disease or problem according to Allopathic Diagnosis
Main Symptoms of Disease
Duration of Disease
Whether it is hereditary?
If due to Diabetes, then how long have you been suffering from diabetes?
Due to any other reason
History of Disease
Chief complaints due to kidney problem
Colour of urine
Is there any difficulty in passing urine?
Blood report, if any
Do you have urine investigation report? (if yes, send its finding)
How many times have you undergone Dialysis?
Urine & Blood report after Dialysis
Have you undergone Blood transfusion?
Have you undergone kidney Transplantation?
If yes, any complaint after Transplantation?
Which medicines have been prescribed after Transplantation ?
Medical reports after Transplantation
Do you have vomiting sensation? In morningIn afternoonIn evening
Frequency of motions
Color of stools
Any constipative tendency?
Urge for food
Preference of food
Regular or Irregular food habit
Desire for water
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