It’s now time for you to outline what’s troubling you.

Name (required)

Gender
MaleFemale

Age (required)

Height (required)
Cm

Weight (required)
Kg

City (required)

Phone No (required)

Email (required)

Occupation

Chief Complaint
(Details about your present Disease/ailments in order of appearance with duration.)

Associated complain:

Past Medication/Treatment taken:

If you have already seen a doctor, what diagnosis did they give you?

What investigations, tests have you undergone? Please mention the reports and brief treatment history.

Family History

Is there anything else that might be helpful or relevant to your problem? including allergies, illnesses that run in the family.

Past History

Diseases or symptoms you have suffered in past, with treatment history

Menstrual history:
(Age of menarche/ menopause/History of abortions or miscarriage)

General Nature:
(Anger, extrovert or introvert, emotional, decision making quality, childhood nature, how you take criticism etc.) and a little bit about your lifestyle and stress even sleep pattern.

Physical Generals

Which weather you prefer most:

Apetite:

Thirst:

Liking for specific taste/food:

Urine:

Stool:

Perspiration:

Thank you for completing the questionnaire.

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