Patient's Name

D. O. B. 

Address

Country

Tel. No.

 Email

Your constitution:
Are you lean, thin, obese, pot – belied? Do you feel tired or energetic at most times of the day?
Chief Complaints:

Please write in detail about the onset, exact location of the Complaints, Sensation, Modalities (better by or worse by - as regards time, position, relation to heat and cold, season) your mental state regarding family, work, environment, fears, just before the onset of disease and few years prior to it.

Duration & History of Present Complaints:

Family History:

Please write about the diseases your parents, grand parents and relatives on maternal side & paternal side had suffered from, including your other blood relations like paternal uncle & maternal aunty.

History of Past Illnesses:

Please write about the diseases you have suffered from, in your childhood and in the recent past, in chronological order. Also please mention about Hospitalization & History of receiving blood transfusion, if any.

Personal History :

Please write about the habits, regular use of medicines of any type, such as tonics, sleeping pills, purgatives etc

History of Vaccinations:
Please write in detail with age at which vaccine was taken.

Have you ever suffered from reaction to any of them ?

Sexual Relations :

Frequency, history of relationship with other than spouse, before and after marriage, history of masturbation

Urine :

Quantity, frequency & associated complaints (If any)

Stool :

Frequency, consistency & associated complaints (if any)

Worms :

Have you ever had any worm or any other Parasitic infestation in the past ? if yes, please give details.

Skin :

Have you ever suffered from any kind of skin disease ? if yes, please give details of the treatment taken. Also please mention your skin type (e.g. dry/oily) Do you have warts, moles or birth marks on any part of the body.

Appetite : How many times do you eat, what and when?

Desires :

Your likings of the food/ drinks/ fruits/ edibles as regards taste, warm, cold etc. Please mention if there is history of any abnormal desires such as Ash, Earth, Lime etc at whatever age.

Aversion :

What are the types of Food/ Drinks for which you have dislike ?

Disagree's :

Does any specific food articles or drink give any problem ?

Thirst :
How many glasses of water do you drink in a day? Do you prefer hot or cold water to drink?

Thermals :

Your likes, dislikes & reactions about the season, such as tolerance/ intolerance to heat, cold, rains, humid weather etc.
How do you relish the open air ?
What is the type of clothing you like for regular use ?

How would you like to bathe, with hot or cold water in what season?

Do you like food hot or cold?

Which season, climate, weather your body cannot tolerate?
Do you require any covering while sleeping? If yes, give details.

Sleep :

How is your sleep. Write in detail including the position during sleep.

Do you perspire during sleep, if yes, in which part is it more. Does it stain?

Does your mouth remain open? Does saliva dribble?

Do the eyes remain half open? Any snoring?

Dreams :

Do you have any specific dreams ? If yes-write the details and the frequency of the same.

Perspiration :

How do you sweat? What is the amount of sweat (Mid/moderate/profuse) Is it more on some particular part of the body? Does it stain? Do you feel better after perspiring or feel worse? Is their any peculiar odour?

Wounds :

Do your wounds heal readily or have any tendency to form pus (suppuration)?
Do you feel that the bleeding from the wounds is normal in quantity?

Dog Bite :

Is there a history of dog bite in the past ? If yes, when ?

Life Space :

Please write a short synopsis about you as a person along with details of your family background, school & college education, business or job satisfaction etc. With an emphasis on any such event in your life which you feel have any relation with that of the evolution of your present state of illness. Your attitude, fears, ambitions, behaviour, emotions etc. Explain in detail with relevant examples.

For Female Patients Only :

1.   History of Menstrual Cycle : Please write in detail about :

Age of Menarche

Regularity of the cycles
Duration, Quantity, Nature of discharge.
Symptoms before, during and after menses.
Leucorrhoea, or any other abnormal discharge, if any.
Last menstrual period.

2.   Obstetric History :

Number of children with age.
Type of delivery with complications, if any.
History of abortions, if any (Natural or Induced)
Whether have undergone surgery for family planning?
If not, methods adopted for family planning.