What are your main
complaints ?
Where are your complaints
located?
What are the sensations accompanying your complaints ?
What makes your complaints worse ?
What makes your complaints better ?
How and when did these complains begin ?
What symptoms have developed most recently ?
What other illness have you suffered in past? Please
describe chronologically
Please describe any disorders of vision, hearing, taste or/ and
smell
How is your appetite ?
What foods do you crave for ?
What food are you averse of ?
What food do not agree with you? and How?
How would you describe your thirst ?
Please describe color, odor, consistency, size, frequency etc of your stools.
Please describe the extent, frequency, color, odor, sediments etc
of your urine.
How is your sexual desire ?
Please describe the frequency, extent, color, odor, consistency etc your
menstruation
At what age did your menstruation begin?
Please describe the color, odor, extent, consistency etc of vaginal discharges
(Leucorrhoea)?
Please describe your sweat regarding the color, odor, consistency,
extent of sweating etc
How is your sleep ?
What kind of Dreams do you get?
What makes you worse in general? Please describe the time
of the day, weather, climate, place, situation, activity etc
What makes you better in general? Please describe the time
of the day, weather, climate, place, situation, activity etc
What are your mental make up? Describe the
personality
Name
Occupation
E Mail (Required)
Age
Sex
Male
Female
Height
Build
Lean
Normal
Obese
Anything Else