www.ramrakha.co.uk


Name
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Name of General Practitioner (GP)
Address of GP
When did you last visit your GP?
Reason for visit
Have you suffered from any disease in the past 18 months?	Yes No
If yes, please describe (enter N/A if answer is no)
Are you under any medications?	Yes No
If yes, please describe (enter N/A if answer is no)
Have you ever taken any Herbal Medines?	Yes No
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How often do you exercise per week?
Do you smoke? If yes, How many a day?
Do you consume alchohol? If yes, how often?
Do you take drugs? If yes, how often?