St.Rita's Hospital provide a facility to you, to seek remedies for your problems. Kindly fill the following details carefully, which may help us to understand your problem and hence can suggest a good treatment to you.

   
 
Name :
Last Name :
Street :
City :
State :
Country :
Zip/Postal Code :
Telephone :
Fax :
E-mail :
Age :
Sex :
Male Female  
Weight :
Structure :
Obese Lean Medium
Occupation & Nature of Work :
Present Complaints with full history :
Past History(Previous problems & surgery) :
Any chronic illness like Diabetes/Hyper tension/TB/Heart Diseases/& medicines taken now :
Have the patient's relatives had the same problem :
Yes No
Any cause known to you for the disease :
State of digestion, motion, micturition, appetite and sleep :
Marital Status :
Married Unmarried 
Treatment done so far :
Recent investigation reports(blood, urine, motion, x-ray, CT scan etc :
Blood pressure :

                                                                 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
   
   
   
 
   
   
   
 
   
   
   
 
   
   
   
 
   
   
   
 
   
   
   
 
   
   
   
 
   
   
   
 
   
 
 

St. Rita’s Ayurveda Hospital and Research Center.

Nalukodi, P.O, Changanacherry, Kerala, India.

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