Dr. Aggarwal’s Ayurvedic Panchakarma & Research
Centre
SCO-79, Phase-2, Mohali, 0172-5027567
www.ayurveda24.co.in
email at: contact@ayurveda24.co.in
Contact Information
1. Name:
6. State:
2. Age:
7. Postal Code:
3. Sex:
8. Country:
4. Address:
9. Phone:
5. City:
10. Phone
(Cel/Mobile):
11. eMail
Address:
Lab Investigations
Date of Test: DD-MM-YYYY
1. HB:
5. Serum Uric
Acid:
2. TLC:
6. Blood Urea:
3. DLC:
7. Serum
Creatinine:
4. Fasting Blood Sugar:
PPBS:
* TLC and DLC stands for Total and Differential Leucocyte Count.
Electrolytes
1. Sodium:
3. Potassium:
2. Calcium:
4. Phosphorus:
Any Additional Reports relevant reports please do attach us a scan copy.
HBA1c :
RA Factor:
1. Urine Routine Test:
2. Ultra Sound Abdomen
Additional Health Questions
1. Your blood pressure? Systolic :
2. Are you diabetic?
Diastolic:
Dr. Aggarwal’s Ayurvedic Panchakarma & Research
Centre
SCO-79, Phase-2, Mohali, 0172-5027567
www.ayurveda24.co.in
email at: contact@ayurveda24.co.in
3. Any family history of disease?
4. Are you allergic to any food, medicine or
weather?
5. Your liquid input and output in 24 hours?
6. How is your appetite?
7. How is your bowel movement?
8. Do you feel any nausea or vomiting?
9. Do you have any breathlessness?
10. Do you feel weak?
11. Do you have any itching?
12. Is there any swelling on face, legs or feet?
16. Please list medicine(s) that you are currently
taking.
17. Any additional Information?
18. How did you hear about us?
(IN LITRES)
Output:
normal