PRELIMINARY DATA :

NAME:

AGE:

SEX: Male Female

ADDRESS :

E-MAIL:

MARITAL STATUS : Single Married Divorced

OCCUPATION :

CHIEF COMPLAINT :

1. Describe your chief complaint in detail by including the location , sensation ( for eg. Type of pain) etc.

2. Write about the origin of the problem ( how did it begin ) and the duration that it has been there for.

3. Describe the progress of the complaint , has it remained the same as from the start or spread , become

   Worse , more painful etc..

   
   
   
4. What aggravates the complaint ? (for eg. Moving , ascending stairs , lying down etc…)

5. What do you do that makes you feel better or ameliorates you ? (for eg. Applying heat or ice, resting)

6. What time of the day is the problem at its worst or does the moon phases affect you ?

   (for eg. Mornings are bad or at night the complaint gets aggravated , the new /full moon affects you)

   ASSOCIATED COMPLAINTS :

7. Do you have any other problems along with the chief complaint ? If yes then describe it in detail as done for the chief complaint .

8. Do you suffer from any other problems which are not associated with the chief complaint ?

PERSONAL HISTORY :

BUILT lean / average / obese

APPETITE - do you eat well or is there any problem while eating ? do you feel hungry or is there a

Loss of appetite since the complaint started ?

CRAVINGS : is there any food item that you like very much or a particular taste that you desire ?

For eg. Sweet , salty, spicy , bitter…

AVERSIONS : is there any food item or taste which you particularly detest ?

FOOD ALLERGIES : are you allergic to any food items or does anything you eat create a problem ?

For eg. Ice – cream causing cold , cold drinks , peanuts , shrimp etc..

THIRST : on an average how much water do you consume in a day ? Do you feel very thirsty or

Are you a thirstless person ? do you prefer your water warm / room temperature / cold ?

HABITS : do you smoke , drink alcohol , chew tobacco , eat pan parag or pan , supari etc..

STOOL : do you have regular bowel movements or are most of the time constipated ? On an average how

Many times a day do you pass a motion ? Is there any difficulty or pain during defecation ?

URINE : how many times a day do you pass urine on an average ? is there any difficulty while passine

Urine ? What is the colour of the urine and does it have a peculiar odour ?

PERSPIRATION : do you perspire ? Describe on what parts of the body you sweat more , does it leave

Any stains (if yes then what colour are the stains) , does it have an offensive smell ?

SEASON : which season of the year do you like the best or in which season does your complaint get

Worse ?

THERMAL MODALITY : are you more prone to feel chilly or hot fast ? does the draft of air affect you

TRAVELLING SICKNESS : do you feel nauseous or giddy while travelling in a bus / car / train / aircraft

Or do you feel like vomiting after a ride on the giant wheel or at sea ?

PAST HISTORY :

Have you suffered from any of the diseases listed here or any other , have you undergone any operations ?

Tuberculosis , malaria , typhoid , dysentry , diabetes , hypertension or hypotension , any skin disease like

Eczema , psoriasis , ring-worm , itch , measles , mumps , herpes , chicken-pox etc…

VACCINATION : which vaccines have you been given ?

FAMILY HISTORY : Is there any disease that is common to your family ? does anybody in your family

Suffer from diabetes , hypertension , tuberculosis , cancer , asthma , any skin

Disorders , arthritis , allergic conditions etc….

FOR FEMALE PATIENTS ONLY :

MENSTRUATION : are your menses regular ? how many days does it last for ? what colour is the blood?

Are the stains difficult to wash ?

Do you have any problems before , during , or after your periods ? (for eg. Acne )

LEUCORRHOEA : do you have any white discharge before / during / after your periods ?

Is it offensive , staining ( if yes then what colour ) , profuse ?

PREGNANCY AND ABORTIONS : how many children do you have ? have all your deliveries been

Normal ? Did you have any difficulty during any of the pregnancies

Or have you had any spontaneous abortions ?

SLEEP : how many hours of sleep do you get in 24 hours ? Do you feel fresh on waking up or do you unrefreshed ? In which position do you prefer to sleep in ?

DREAMS : do you get any dreams ? If yes then do you remember them on waking , or are they forgotten ?

Describe any dream which you remember ? What is your interpretation of this dream ?

PERSONALITY AND TEMPERAMENT :

1. How would you describe yourself as a person ?

2. Do you weep / get angry / irritable / sad / depressed / nervous easily ? Also in what situation do these

3. Emotions become more evident or more exaggerated ?

4. Do you have any tension about anything in particular ? Do you get nervous , anxious very fast and about what?

5. Have suffered from any tragic incident or shock in the past ? how did you deal with it ?

6. Are you happy currently , do you have any regrets , misgivings ?

7. Do you fear anything (for eg. Fear of darkness , being alone , illness ) ?

8. Please feel free to write any thing about yourself , your sexual activities , likes and dislikes etc..