MNBMTREATMENT FORM
 

Name:
 
Designation:
Address:
Tel Home :
Work:
E-mail:
Sex : Male
Female
Height:
Weight:
BP:
Diet: Vegetarian     Non-vegetaruan
Smoking        Alcohole        Profession
Profession
Exposure to Computers :  Yes
 No
Exposure to Chemicals at place of work at any time in the past :     Yes      No
Describe :
Reffered to our HEALTH CENTRE BY
IN CASE OF WOMEN
Is your M.C. Regular :  Yes
 No
Caesarean Operation :  Yes
 No
At  Age :
Puberty :
Menopause :
Hysterectomy :
YOUR MEDICAL HISTORY:
MEDICINES BEING TAKEN :
PRESENT SYMPTOM :

_________________________________________________________________________

DECLARATION : 

I the undersigned, do hereby state declare & confirm as under;

  1. That I on my own free will & consent is submitting myself and / or undergoing the treatment " AKHAND CHIKTSA", which is based and ancient Indian holistic healing techniques popularity known  as " ALTERNATE THEARAPY".

  1. That  the said treatment offered by you is not a substitute for regular medication or an alternative to expert  medical attention or treatment.

  1. That the said treatment is not intended to replace conventional medicines but rather is intended to complement rejuvenate and enhance the natural body systems.

  1. That if necessary and in the event, my illness continues or aggravate, I shall consult a competent medical practioner immediately irrespective of whether I continue this treatment or not.

  1. That in the course of the said treatments which to my knowledge essentially involves the passage transmission and movement of energies from the body of the therapist to that of the patient or vice versa I shall have no objection if in connection with the said treatment any physical contact or ouch of the affected portion of my body is made by my therapist

  1. That I will have no objection of any nature whatsover that incase of my therapist for the purpose of this record and analyses of the line of treatment rendered to my any photographic process for the said purpose on which I shall have no claim of any nature whatsover.
                                                                                              
 

 
 

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