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    Name

    Address



    Residence Number

    Mobile Number

    Email

    Age

    Sex

    D.O.B

    Diet

    Marital Status

    Occupation (Nature of Work)

    Education

    Referred to us by

    Previous Diseases & Drugs Used

    Disease suffered from, Age, Duration

    Whether you completely recovered

    Medicines & treatment taken

    Any other particulars

    Family History

    List of Major Diseases

    Personal History

    Did your mother have any problem during pregnancy?

    Did she take any drugs during pregnancy? What were they?

    Was there any difficulty about your birth? Give Details.

    At What Age Did You Start

    Teething

    Sitting

    Standing

    Walking

    Speaking

    Urine control / bed-wetting etc.

    Eating indigestible like chalk, lime, earth, state-pencil, etc.

    Any other problem about your growth & development?

    Vaccination & Inocculations

    Was there any reaction or particular trouble after any of above vaccination or inocculations?

    Give Details

    Number of children living and dead

    If dead, state causes

    Any abortions, miscarriages or still births?

    Your Habits

    MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES : (AND DETAILED HISTORY OF THE PRESENT ILLNESS, THE ONSET AND COURSE WITH DATES)

    Appetite & Thirst

    How is your appetite?

    When are you most hungry?

    What happens if you have to remain hungry for long?

    How fast do you eat?

    How much thirst do you have?

    Do you feel any change in your taste and feeling in your mouth?

    Bitter Food

    Salt Extra

    Sweet Food

    Sour Food

    Bread

    Butter

    Fats
    Milk

    Coffee

    Mud / Chalk

    Spicy Food

    Cabbage

    Onions

    Warm Food / Drink

    Cold Food / Drink

    Fruits

    Stool

    Do you have any problem regarding your stools?

    Do you have to strain for stool? Even if soft?

    When and how many times a day you pass stools?

    Do you have any problem about bowel movements?

    Do you have belching or passing gas? Describe its character

    Urination & Urine

    Any problem about urine?

    Any strong smell? Like what?

    Any difficulty about the flow? Slow to start, interrupted, feeble, dribbling etc.?

    Any involuntarily urination? When?

    Do you have any trouble before, during and after passing urine? After passing urine, sometimes 2-3 dropping of urine most of the time but not always?

    Sweat / Perspiration - Fever - Chill

    How much do you sweat?

    Where and on what part do you sweat most?

    Do you perspire on the palms or soles?

    What is the smell like? E.g. foul, pungent, sour, urinous

    Is the sweat warm, cold, clammy, sticky, musty, greasy, stiffens the linen etc.?

    Sleep

    Describe your posture in sleep, on the back, side, abdomen etc.

    During sleep do you

    Describe if anything else is unusual about your sleep

    Sweat / Perspiration - Fever - Chill

    How is your sexual desire?

    How do you feel after sexual intercourse?

    Do you suffer from any sexual disturbance?

    Any particular feeling or symptoms appear before, during or after sexual intercourse?

    Any habit like (masturbation etc.) in past as well as present? How often?

    Any homosexual inclination?

    Any difficulty in erection?

    What is the method you use for family planning (contraception)?

    Did you suffer from any sexually transmitted disease? Syphilis? Gonorrhoea? Herpes? HIV?

    Weak erection? Failing erection? Describe.

    Any other trouble in sex? Describe in details.

    Mind

    It is now universally acknowledged that your mind has tremendous influence on your body. For giving proper treatment it is absolutely necessary for us to understand your emotional and intellectual nature. We can thus treat you as a whole. In order to understand you we will be asking certain questions. Answer them freely, carefully and completely. This information will help us much in giving you the correct remedy. Also such a remedy will help improve your mental make up. Answer freely. Answer frankly. Answer completely.

    Are you anxious? About which matters?

    Are you doubtful or suspicious? Of what?

    Are you fearful of anything such as animals, people, being alone, darkness, death, disease, robbers, sudden noises, thunder, of the future, of something unknown, high places, etc.?

    What are you jealous about? Of whom? From what symptoms do you suffer when jealousy?

    In which matter are you impatient? Hurried?

    How much revengeful are you?

    How long do you remember hurts caused to you by others?

    Do you ever become suicidal? When? If so in what manner do you contemplate to end your life? Even then, are you afraid of dying?

    When are you cheerful?

    Are you sexual-minded?

    Any unwanted thoughts any time? What are they?

    Have you any imaginary sensations or fears?

    How is your memory? For what is it poor? e.g. names, places, faces, what you have read, etc.

    Do you hear voices, or that you are called, or anything else in this line keeps on occurring in your mind unduly?

    Do you weep easily? What makes you weep? How do you feel after weeping?

    How do you feel if someone offers sympathy and consolation?

    Are you easily irritated? What makes you angry?

    What bodily symptoms do you develop when angry? e.g. trembling, sweating etc.

    Do you like company? Or like to remain alone?

    How seriously are you affected by disorder and uncleanliness in your surrounding?

    What are the greatest griefs that you have gone through in your life?

    What are the greatest joys that you have had in life?

    What activities you deeply like? Are there any matters which you deeply dislike?

    In your opinion, which aspects of your mind and moods are not agreeable to you. Inspite of your awareness and maturity, are you unable to change these aspects?

    Give a clear cut picture of your situation in life and your relationship with each of your family members, friends and associates in work.

    How the future looks to you?

    When you are free, what thoughts come to your mind Are you worried or unhappy over any personal, domestic, economical, social or any other condition? If so describe in detail

    If asked for 3 desires or wishes in life, what will you ask for?

    Check types of dreams that you have

    By whom?

    For what?

    If any other, specify here

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