01. Intro 02. Physical Generals 03. Mental Generals 04. Complaints Phone Name * First Last Age * Age Sex select_sex Male Female Address * Include Nationality Address Email * Email Occupation select_occupation Diet select_diet Vegetarian Non-Vegetarian Both Marital Status select_maritalstatus Married Unmarried Height(Ft) & Weight(Kg) Height & Weight Appetite (Diet) select_appetite Normal Increased Dereased Thirst select_thirst Normal Increased Dereased Urine Color Pale, Yellow,Clear Mixed with blood, foamy etc.. Urine Frequency select_urine_frequency Normal Increased Dereased Stool select_stool Normal Loose_Stool Constpated Sweat select_sweat Normal Profuse (increased) Scanty (decreased) Sleep Pattern select_sleep Normal Sleepy Feeling Lack of Sleep/Insomnia Thermals (Which weather affects you more) select_weather Normal in all Weather Hot Weather Cold Weather Describe Yourself, Your Strength, Ambition and Weakness Your Nature Describe Yourself Are you Anxious ? About What ?What makes you angry ? Are you Anxious ? Do you like to be in company or like to be alone ?- Do you weep easily? If someone console you when you are upset, does it help or worsen the situation ? do you like yo be in Company? How is your memory ? (Hint – Good, Poor, Forgetful, etc..) – Do you have fear of anything ? How is your memory? Main Complaint Location, Sensation when does it increase and decrease Main Complaint Past History Any other major illness in past and its treatment Past History Family History Mention Diseases that happen to occur in your blood relations (Example – BP, Thyroid, Sugar, Asthma, etc..) Family History Medicinal History Taking medicines, if any ? Please mention disease and name of medicine Medicinal History Latest Medical Reports, if any ?
