Name: ....... ...................Age: .............Date: .............

Veg Non Veg Egg Veg

Address:
Email: Occupation: Education ....

Single Married Divorced ............Male Female
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1.Previous Diseases & Drugs used:           

2. FAMILY INFORMATION
Cancer    Diabetes  Insanity  T.B     Epilepsy/Fits,     Bleeding Tendency    
Eczema     Asthma      Paralysis    Hypertension    Heart    Kidney     Liver Problems

3. PERSONAL  HISTORY  : Habits
Smoking      Snuff      Chewing Tobacco     Alcohol      Tea  Coffee     Sleeping
Pills      Laxatives Any other

4. MAIN COMPLAINTS  AND OTHER ASSOCIATED TROUBLES
Where is the trouble  / what exactly does you feel or have there / What are the factors  that makes  this trouble  better  or worse ? / Onset of trouble 

5. APPETITE  & THIRST

6. LIKE /DISLIKE/DISAGREES

(please Enter whether you 'like' or 'dislike' or 'disagree' the following in the space provided)

Bitter	Salt Extra	Sweet	Sour	Bread
Butter	Fats	Milk	Fish	Chalk
Eggs	Spicy Food	Meat	Fruits	Cabbages
Onions	Warm food- Drink	Cold Food-Drink	Anything Else:

7. Sweat / Perspiration / Fever- chill /  Time
How much  your sweat ? Where and on what part do you sweat most ? Do you perspire on the palms or soles ? Is the sweat  warm cold clammy sticky musty greasy staines the linen ?

8. STOOL, URINATION & URINE

9. SLEEP: Posture in sleep cover or uncover
....DREAMS

10. WHEATHER : Change Cloudy Cold Dry Wet Hot Rain Storm Warm & Wet

11. SEXUAL SPHERE (General)
Any particular feeling or symptoms appear before during  and after sexual intercourse ? , Do you  have increase desire or decreased desire for sex ?

FOR MEN
Any difficulty in erection ?  Wanted erection  ? Unwanted erection ? Weak erection / Failing erection  - Describe ?
Any other trouble  in sex ?

FOR WOMEN
Menses: How are the periods - Regular / irregular and at what  age  did it start  ? Was any trouble  then ? Mention interval between periods.No. of days of flow.  Menstrual flow: is there any change now in Quality / Colour / Smell or Consistency ? Are stains difficult to wash  ? Yes, No. Do you  noticed any variation  in quality and quantity of flow during menses ? How & When ? Do you suffer in any way before, during or after  menses if so describe: What symptoms did you  suffer during  menopause ? Do you feel the internal  parts coming down ? Is there any white discharge ?   Nature / Colour / Consistency / Smell, When & under what  circumstances  it more or less, has the discharge any relation to menses ? Do you pass any gas  from Vagina  ?  Yes, Any trouble with Breasts ?

12. MIND

(About your mental state and your emotional nature. Please answer in this part about your situation in life and about all the things that are bothering you. Be frank and open)

Are you anxious about which matters ?  

Are you fearful of anything such as Animals People Being Alone Darkness Death Disease Robbers Sudden Noise Thunder Of the Future Of  something unknown
High places Timidity or any other  

Are you doubtful or suspicious ? of what ?
What are you jealous about ?  of whom ? , From what symptoms do you  suffer when jealous ?
In which matters are you impatient ? Hurried ?
How long do you remember hurts came to you by others ? Offended easily ?
How much revengeful  are you ?
What are  you proud of ?
Does your pride get easily hurt ? (Egotism)
Depressed / Brooding etc. ?
Do you  ever become suicidal ?	Yes No
When ?
If so  in what manner do you  contemplate  to end your life ?
Even then are you  afraid of dying ?	Yes
When are you cheerful ?
Are you sexual minded ?
Any unwanted thoughts any time ? What are they ?
Have you any imaginary sensations or fears ?
Do you hear voices as that you are called or anything else in this line keeps on occurring in your mind unduly ?	Yes No
How is your memory ?
For what  is poor ? e.g. names, places, faces, what you have read, etc.
Do you weep  easily ?	Yes No
What makes you weep ?
How do you feel after weeping ?
How do you feel if someone offers sympathy and consolation ?
Are you easily irritated ?	Yes No
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 uncleanness in your surroundings ?	Yes No
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 mind and moods are not agreeable to you. In spite of your awareness and maturity, are unable to change this  aspect ?
GIve a clear  cut pircure  of your situation  in life and your relationship with  each of your family members , friends and associates  in work.
How does the future look to you?

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