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Treatment

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Name :
Sex :
Male Female
Age :
Email :
Phone :
Occupation :
Address :
Present problems :
     
Nature :
Mild-tempered Irritable Emotional
Angry Talkative Melancholic
Crying Hopeless Suicidal
Murderous Grief-stricken Introvert
Lazy Active Forgetful
Anxious Fastidious    
Fear of indifferent to religious
     
Cravings :
Sweet Warm food Hot-spicy food
Cold food Hot drinks Cold drinks
Egg Unusual things (paper/soil)    
     
Addiction :
Alcohol Smoking    
Tobacco Chewing Betel Nut    
     
Feel better in :
Summer Winter Monsoon
Hill region Seaside    
     
Likes :
Warm Cold Open Air
Solitude Company    
     
Past diseases history :
Pox Typhoid Measles
Mumps Jaundice Physical injury
Mental trouble Skin disease Venereal disease
Stroke Piles Fistula
Renal disorder
Surgery for
     
Vaccine :
Triple antigen Hepatitis Tetvac
Antirabies BCG Measles
     
Comfortable lying on :
Back Left Right
Face Painful Side  
     
Current medication for :
Hypertension Insomnia Diabetes
Cardiac problem Asthma Epilepsy
Birth control Rheumatism Constipation
Acidity Migraine
Other
     
Body :
Obese Medium    
Thin Skiny    
     
Thirst :
Usual Excessive    
Less Nil    
     
Appetite :
Usual Excessive    
Less Nil    
     
Time of rise of symptoms :
Early morning Morning Fore noon
Afternoon Evening Night
Mid night Any fixed time    
     
Stool :
Hard Medium Soft
Liquid 1 times daily 2 times daily
3 times daily Aching No urging
With strain Gap of days
     
Urine :
Yellow Reddish Watery
     
Dreams :
Rats Thieves Ghosts
Dead people Falling from heights Exams
     
Lateralities :
Right-sided Left-sided
     
Diseaes in family (paternal/maternal) :
TB Cancer Rheumatism
Syphilis Gonorrhoea Mental disorder
 
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