Forms

Your Name (required)

Gender
 Male Female

Age

Phone

Your Email (required)

Address

Occupation

Height

Weight

Chest

Married
 Yes No

If Yes, Spouse Name

Present Complaints

When is the signs and symptoms of the present complaints appear first ?

Which is the side more affected ?

Appearance of the affected parts

When is the disease felt more, time ?

Feeling of relief comes by

GENERALITIES

Complexion

Head

Nose

Lips

Nails

Taste

Neck

Abdomen

Face

Forehead

Cheeks

Ears

Appetite

Tongue

Stools

Scalp

Eyes

Hair

Skin

Thirst

Throat

Urine

Others

Anxious , worried, cheerful, sad, shy , etc ?

Memory : Thoughts :

Bad habits, if any?

Mild, yielding or irritable, quarrelsome, jealous, etc.:

Liking/disliking for sweat/ saltish Chilly/Hot:

Liking/disliking for cold/warm food

Liking/disliking for cold/warm drinks

What type of season suits best?

Which type of season is uncomfortable?

Which type of season/climate aggravates the disease?

Whether likes to remain in closed room or in open air, even if the cold open air?

Any kind of discharge ( indicate either thick, thin, white, yellow, bloody, green, blue, Etc) ?

History of any previous illness?

History of TB, Cancer, etc in the family ?

( both maternal / paternal ) ?

( both maternal / paternal ) ?

ADDITIONAL INFORMATION TO BE GIVEN BY THE FEMALE PATIENTS
Menses:

(a) When appeared first?

(b) Any complaint since then ?

(c) Present position:

(d) Are they painful and how the pain is relieved ?

(e) What is its colour ? Bright red, dark, brown, black, clotted, etc ?

(f) Complaints during, before and after menses, if any ?

(g) When does it flow more ?

(h) How long it remains ?

Leucorrhoea :

(a) Whether thick or thin ?

(b) Bland or acrid ?

(c) Cold or hot (d) Colour ?

(d) When does it flow more ?

Any other information, such as any complaint since last delivery, painful coitus, sexual desire, etc ?

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