PAIN MANAGEMENT

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Date of Birth *

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Gender * Male Female

Marital Status * Married Single Divorced Widowed

Description Max: 190 Character

Current Medical Condition

Current Medications, Herbal Supplements & Vitamins (Daily Dose, Start Date,Name of Perscriber)

Allegiance Adverse Reaction to Treatment

Presenting Problem

Treatment

OBSERVATIONS	PITTA	KAPHA
Body Size	Slim	Medium	Large
Body Weight	Low	Medium	Overweight
Chin	Thin,angular	Tepering	Rounded,double
Cheeks	Wrinkled,sunken	Smooth flat	Rounded,plumb
Eyes	Small,sunken,dry,active,black,	Sharp,bright,gray,yellow/red,	Big,beautiful,blue,calm,loving

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