| Country
of Birth |
|
| E-Mail |
|
| Occupation |
|
| Education |
|
| Birth
Date |
|
|
YOUR
COMPLAINT |
|
| Prime
Complaint |
|
| Since
when (Duration) |
|
|
HISTORY OF
COMPLAINT |
|
| Brief
History of Disease / Complaint |
|
| Other
Complaints |
|
| How
did it start? |
|
| Where
(body part & country) it started? |
|
| When
& how does it get aggravated? |
|
| When
& how does it get alleviated? |
|
| What
have you done for it? |
|
| Is
there any proper Diagnosis. If
so what is it? |
|
| Are
you on any medication for it? |
|
| Have
you ever taken Ayurvedic treatment for it? |
|
|
HISTORY OF
YOUR HEALTH |
|
| Brief
History of your Health from Birth |
|
| How
was your birth? |
Normal
Caesarean
|
| How
was your health during childhood? |
|
| Any
major illness? (If
yes what treatment was taken?) |
|
| Any
other thing related to your health that you would like to
mention? |
|
| Currently
are you on any other medication? |
|
Does
anyone from your father’s or mother’s side or siblings or
grand parents’ side
suffer or ever suffered from same complaints / illness &/or
any other major
illnesses? |
|
| Vegetarian/Non
Vegetarian/Vegan |
Non
Vegetarian Vegetarian
Vegan |
| Your
daily brief routine or schedule? |
|
Your
diet
Regular/Occasional
What you eat?
Quantity?
Frequency per week?
|
|
How
is your appetite?
(Good/ Moderate/ Low/ Bad) |
|
What
do you think of your digestion?
(Good/ Moderate/ Low) |
|
| How
much water do you take during day? |
|
How
are your bowels?
Regular
/ Irregular
Feeling empty & light / Not really
Quantity (Heavy / Moderate / Low)
No of times per day
Quality (Well formed / Dry hard / Semi solid / Watery / Sticky)
Duration (Takes a while / Easy release)
Smell (Normal / Foul) |
|
| How
is your urination? |
|
| Do
you get the burps? If
yes how are they, clear or with food taste or with reflux? |
|
| Do
you feel ‘hungry’? |
|
| Do
you pass wind?
If yes, how often and is it smelly? |
|
| Do
you get ‘Bloated’ or ‘Gurgling’ in the abdomen? |
|
| If
you ‘eat’ again after eating, how do you feel? |
|
| If
you don’t eat, how do you feel? Do you sustain hunger? |
|
| How
is your sleep and sleep pattern? Do
you feel fresh when you wake up? |
|
| How
is your ‘Mind’? e.g.
Hyper Active, Quiet etc. |
|
| How
do you manage ‘Stress’? |
|
How
do you express yourself?
(Properly
/ Not totally / Incorrectly / Hide & suppress feelings) |
|
| What
is your energy level? |
|
| Do
you exercise regularly? |
|
| How
is your social life?
Are you an active participant or passive? |
|
How
is your relationship with your partner & friends?
(e.g. Open & Interactive, Excellent) |
|
| How
is your ‘Sex Drive’? |
|
What
is your ‘Menstrual cycle’ History?
(e.g. Regular-Irregular, Painful etc.). |
|
| Do
you drink alcohol? If
yes, then how many times and how much per week? |
|
Do
you go to pubs etc? If
yes how many times per
week? |
|
| Do
you smoke? If
yes, then how many per day? |
|
| Do
you take any drugs? If
yes, what are they and how many times a day or week? |
|
| Do
you take coffee or tea?
If yes, which drink and how many cups per day? |
|
| Do
you have any allergies? If
yes, since when and what have you done for them? |
|
| Latest
Laboratory reports etc. if any? |
|
| Anything
else you would like to tell us? |
|
