• Introduction
  • Physical Generals
  • Mental Generals
  • Complaints

Introduction

First Name

Last Name

Age

Sex

Address Include Nationality

Email

Occupation

Diet

Marital Status

Height (Ft.) & Weight (Kg)

Physical Generals

Appetite (Diet)

Thirst

Urine Color (Pale, Yellow, Clear, Mixed with blood, Foamy etc..)

Urine Frequency

Stool

Sweat

Sleep Pattern

Thermals (Which weather affects you more)

Mental Generals

Describe Yourself, Your Strength, Ambition and Weakness Your Nature

Are you Anxious ? About What ?What makes you angry ?

Do you like to be in company or like to be alone ?- Do you weep easily? If someone console you when you are upset, does it help or worsen the situation ?

How is your memory ? (Hint – Good, Poor, Forgetful, etc..) – Do you have fear of anything ?

Complaints

Main Complaint Location, Sensation when does it increase and decrease

Past History Any other major illness in past and its treatment

Family History Mention Diseases that happen to occur in your blood relations (Example – BP, Thyroid, Sugar, Asthma, etc..)

Medicinal History Taking medicines, if any ? Please mention disease and name of medicine

Latest Medical Reports, if any ?

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