Consultation Form
Patient's Name
Address
Country
Tel. No.
eMail
   
Chief Complaints :
Please write in details about the onset exact location of the Complaints, Sensation, Modalities (I-e.) better by or worse by) as regards time, position, relation to heat and cold, season, time etc.
Duration & History of Present Complaints :
Family History :
Please write about the diseases your parents, grand parents and relatives on maternal side & paternal side had suffered from, including your other blood relations like paternal uncle & maternal aunty.
History of Past Illnesses :
 Please write about the diseases you have suffered from, in your childhood and in the recent past, in a sequential order of age. Also please mention about Hospitalization & History of receiving blood transfusion, if any.
Personal History :
Please write about the habits, regular use of medicines of any type, such as tonics, sleeping pills, purgatives etc
History of Vaccinations :
Have you ever suffered from reaction to any of them ?
Sexual Relations :
Desire, frequency, relation to chief complaints, if any.
Urine :
Quantity frequency & associated complaints (If any)
Stool :
Frequency, consistency & associated complaints (if any)
Worms :
Have you ever had any worm or any other Parasitic infestation in the past ? if yes, please give details.
Skin :
Have ever suffered from any kind of skin disease ? if yes, please give details of the treatment taken. Also please mention your skin type (e.g. dry/oily) Do you have warts or moles on any part of the body.
Appetite :
Desires :
Your likings of the food/drinks/edibles as regards taste, warm, cold etc. Please mention if there is history of any abnormal desires such as Ash, Earth, Lime etc.
Aversion :
What are the types of Food/Drinks for which you have dislike ?
Disagrees :
Does any specific food articles or drink precipitate any problem ?
Thirst :
Thermals :
Your likes dislikes & Reactions about the season, such as tolerance/intolerance to heat, cold, rains, humid weather etc.
How do you relish the open air ?
What is the type of clothing you like for regular use ?
Do you experience burning sensation in any part of the body ? If yes, give details.
Do you feel that there is excessive salivation in your mouth ?
Does the saliva dribble during sleep? Is there any offensive odour ?
Sleep :
How is your sleep. Write in details including the position during sleep.
Dreams :
Do you have any specific dreams ? If yes-write the details and the frequency of the same.
Perspiration :
How do you sweat ? What is the amount of sweat (Mid/moderate/profuse) Is it more on some particular part of the body ? Does it stain ? Do you feel better after prespiring or feel worse ? Is their any peculiar odour ?
Wounds :
Does your wounds heal readily or have a tendency to suppuration ?
Do you feel that the bleeding from the wounds is normal in quantity ?
Dog Bite :
Is there a history of dog bite in the past ? If yes, when ?
Life Space :
Please write a short synopsis about you as a person alongwith details of your family background, school & college education, business or job satisfaction etc. With an emphasis on any such event in your life which you feel have any relation with that of the evolution of your present state of illness.
For Female Patients Only :

1. History of Menstrual Cycle : Please write in detail about :
Age of Menarchee
Regularity of the cycles
Duration Quantity , Nature of discharge.
Symptoms before, during and after menses.
Leucorrhoea, or any other abnormal discharge, if any.
Last menstrual period.

2. Obstetrical History :
Number of children with age.
Type of delivery with complications, if any.
History of abortions, if any (Natural or Induced)
Whether have undergone surgery for family planning?
If not, methods adopted for family planning.