• Name :
  • Age :
  • Gender :
  • Address :
  • City :
  • Mobile no. :
  • E mail :

Please give us the following details related to each problem separately. Please mention in terms of –

  • Site and area of illness.
  • Type of sensation or feeling trouble.
  • Effects of time, circumstances, food, weather and temperature, physical, mental and emotional factors-making the sickness worse or better.
  • Any other symptoms which appears or appeared simultanious with the problem.
  • Describe, how and when trouble started and progressed to the present state.
  • Treatments taken.
  • Present illness –
  • Past illness (Full history of all diseases suffered since birth)
  • Some general things about patient.
  • Physical generals –
  • a. Desire/carving – food and drinks.
  • b. Taste of mouth –
  • c. Thirst –
  • d. Sleep –
  • e. Appetite –
  • Health status and diseases in family members –
  • Mind – your nature in detail ?
  • Any stress condition ?
  • Any fear ?