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1. PERSONAL INFORMATION
Name : Age :
Address(with pincode  & phone/mob numbers) :  Email :
Occupation : Education :
Gender :
Eat :
Marital Status :
2. Previous Diseases & Drugs used:
3.  FAMILY INFORMATION


4. PERSONAL HISTORY : Habits


5. MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES
Where is the trouble / what exactly does you feel or have there / What are the factors that makes this trouble better or worse ? / Onset of trouble
6. APPETITE & THIRST
7. LIKE /DISLIKE/DISAGREES
Bitter: Salt Extra: Sour: Sweet:
Bread: Butter: Fats:  Milk:
Fish: Chalk: Eggs: Spicy Food:
Meat: Fruits: Cabbages: Onions:
 Warm food- Drink: Cold Food-Drink: Anything Else:
8. Sweat / Perspiration / Fever- chill / Time
How much your sweat ?
Where and on what part do you sweat most ?
Do you perspire on the palms or soles ? Is the sweat warm cold clammy sticky musty greasy staines the linen ?
9. STOOL, URINATION & URINE
10. SLEEP: Posture in sleep cover or uncover
DREAMS:
11. WHEATHER
12. SEXUAL SPHERE (General)
Any particular feeling or symptoms appear before during and after sexual intercourse ?
Do you have increase desire or decreased desire for sex ?
FOR MEN
Any difficulty in erection ? Wanted erection ? Unwanted erection ? Weak erection / Failing erection - Describe ? Any other trouble in sex ?
FOR WOMEN
Menses: How are the periods - Regular / irregular and at what age did it start ? Was any trouble then ? Mention interval between periods.No. of days of flow. Menstrual flow: is there any change now in Quality / Colour / Smell or Consistency ? Are stains difficult to wash ? Yes  No .Do you noticed any variation in quality and quantity of flow during menses ? How & When ? Do you suffer in any way before, during or after menses if so describe: What symptoms did you suffer during menopause ? Do you feel the internal parts coming down ? Is there any white discharge ? Nature / Colour / Consistency / Smell, When & under what circumstances it more or less, has the discharge any relation to menses ? Do you pass any gas from Vagina ? Yes  No Any trouble with Breasts ?
13. MIND
(About your mental state and your emotional nature. Please answer in this part about your situation in life and about all the things that are bothering you. Be frank and open)
Are you anxious about which matters ?
Are you fearful of anything such as



Are you doubtful or suspicious ? of what ?
What are you jealous about ? of whom ? , From what symptoms do you suffer when jealous ?
In which matters are you impatient ? Hurried ?
How long do you remember hurts came to you by others ? Offended easily ?
How much revengeful are you ?
What are you proud of ?
Does your pride get easily hurt ? (Egotism)
Depressed / Brooding etc. ?
Do you ever become suicidal ?
When ?
If so in what manner do you contemplate to end your life ?
Even then are you afraid of dying ?
When are you cheerful ?
Are you sexual minded ?
Any unwanted thoughts any time ? What are they ?
Have you any imaginary sensations or fears ?
Do you hear voices as that you are called or anything else in this line keeps on occurring in your mind unduly ?
How is your memory ?
For what is poor ? e.g. names, places, faces, what you have read, etc
Do you weep easily ?
What makes you weep ?
How do you feel after weeping ?
How do you feel if someone offers sympathy and consolation ?
Are you easily irritated ?
What makes you angry ?
What bodily symptoms do you develop when angry ? , e.g. trembling, sweating etc.
Do you like company ? or like to remain alone ?
How seriously are you affected by disorder and uncleanness in your surroundings ?
What are the greatest griefs that you have gone through in your life ?
What are the greatest joys that you have had in life ?
What activities you deeply like ?
Are there any matters which you deeply dislike ?
In your opinion, which aspects of mind and moods are not agreeable to you. In spite of your awareness and maturity, are unable to change this aspect ?
GIve a clear cut pircure of your situation in life and your relationship with each of your family members , friends and associates in work.
How does the future look to you?
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