ইংরেজি ফরম EVER GREEN HOMOEO HOME SERVICEPatient Name: Fathers / Husband Name : Age (dd-mm-yyyy) : Address : Name of the Disease : Duration of the Disease : Present Problem : Present Symptoms : Previous Condition of the patient : Mental Condition : Had feel such Disease before and how long : Skin Disease : Stool: How many times a day? Any Serious diseas you have Attacked before : if any:Bite of any kind of Animal : Any Preventive/Have You Taken : YesNoFamily history of : MadT.BCancerAsthmaSuicidal TendencyStomachpainAcidityHow feeling you food test : GoodBadOtherWhat Kind of Food you like : HotColdSuggerChilyRichfoodColour of eyes : RedBrownWhiteOffwhiteNaturalCondition of Tongue : Dry LyerBlack LyerSide Black LyerBlood Pressure : highlowUrine : Albomin(+)Albomin(-)YellowwhiteRedNormalSleeping Condition : RegularirregularHow Many Time DayNightPhysical Condition : weaknessHealthyMediumCondition of Swept/ Any Smell or not : How Feeling you winter season and hot season more hot or more cold : Others Problem if any : Urine (if any sugar ? ): YesNoCondition of teeth: Any kind of Affect of Teeth?Insecticide?SeasesInjection or piel?The history of family : Urine / Burning / Quantity Urine (if any Layer ? ): YesNoNote Other:(if any) For Women OnlyAny birth Control Injection Yes/No: YesNoLigation : YesNoBrest Any : TuomarPainPainlessAny kind of hipojointpain : YesNoHeadache : SometimeAlwaysLeucorrhoea : Uterus Condition : Ministration : RegularirregularHow many times a day? For Child OnlyNormal / Crazy / Talent / Not : NormalCrazyTalentNot :Winters Tendency : Sleeping Condition : Email Email VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: Share this:FacebookTwitterRedditLinkedInPinterestPocket