Name

Age & Sex

D.O.B

Religion

Occupation

Marital Status

Contact Numbers

Referred to us by

Present complaint and its details:

When & How it started:

What makes it worse:

What makes it better:

Details of any other associated problems along with the main complaint:

Which weather is not tolerated by you or your problem?

What time, weather, and season your problem is maximum?

What is the most comfortable position for you during sleep?

Any unusual thing that happens to you like talking..teeth grinding..walking in sleep etc...

What do you like to eat or drink?

What do you dislike to eat or drink?

Any food item that gives you any problem:

Any habits like smoking, sleeping pills, laxatives etc...

How much amount of water you drink normally?

Any complaint in urination or passing stool:

Any sexual or personal problem you face..

Male (Indulgence in past & present, Habit of masturbation...If any erection problem…if any other trouble in sex Inclination to homosexual)

Female sexual sphere.. Related few question..

Discomfort during or after making a relation
Increased desire or dislike to sex

Any discharge per vagina, colour, stain, easy to wash or not

Any prob related to periods

(pain or discomfort in body-

Average cycle is of how many days?

L.M.P
Number of days of bleeding

Bleeding character-(flow more/less- color clots etc..)

Any other changes before during & after Menses?

At what age your menstruation cycle started and associated prob during that time

No.of Childbirths

Method of deliveries-

Abortions if any-

Problems faced during the pregnancies

Changes before and after deliveries & abortions;if any-

Family history-any major illness;

Past medical history

Major diseases suffered-(Diab anaemia cancer t.b. Rheumatism epilepsy...asthma.heart trouble..kidney trouble..liver...hypertension Any accident or surgery etc)
Any long illness,if evr had & treatment taken

Any allergic reaction to any food mdcn or anything

Any Animal bite or anything & treatment taken

FEARS

DREAMS

CHILDHOOD MEMORIES

(GOOD, BAD)

WHAT UPSETS YOU EASILY

WHAT YOU LOVE TO DO

WHAT YOU HATE

WHAT MAKES YOU HAPPY

HAPPIEST MOMENT OF LIFE

WHAT MAKES YOU SAD

WORST MEMORY OF LIFE

HOW YOU THINK YOU ARE DIFFERENT FROM OTHERS

Is there anything else you would like to communicate?