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Name:
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Date of Birth:
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[dd-mm-yyyy]
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Postal Address:
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Phone No:
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E-mail Address:
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Occupation:
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Day/Month/Year:
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Please describe
yourself (patient) in appearance including approximate weight
and height. |
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Describe your
chief complaint in detail. The following are some of the
relevant details required.
i) If this
is a physical problem, which part of the body is affected?
Please specify the location. When did this problem begin? Is
it periodic or recurrent? If yes, then how often? For how
long do the symptoms last?
ii) Describe the symptom(s) you are experiencing. Explain
this with the area of distribution and the sensation
experienced. Please give complete details and describe what
you feel. For eg: – the pain is intense, like a knife stabbing
me; or the itching is so unbearable, I wish I could cut that
part off; or I feel so anxious, it seems like the end of the
world has come.
iii) What are the modalities that cause the trouble to worsen
or improve? Give details with regard to time, temperature,
climate/weather, food items eaten, applications, movement,
rest, and any emotional changes which occur.
iv) Add any other symptom that you find related to your chief
complaint that is not mentioned above, including how you feel
in general while the complaint is present.
v) What circumstances preceded or were occurring around the
time that your problem began to occur?
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Describe in detail
in the above format any other problems that you may be
experiencing, eg., headaches, bowel related problems,
colds/sinusitis, backaches, hypertension, diabetes, etc.
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Past History:
Please give details of the different sicknesses you have
suffered from since childhood with approximate dates in month or
year. Also detail the treatment used for the condition and the
intensity of symptoms experienced. Anything out of the ordinary
is appreciated. Please add the present prescription of medicines
that you are on as well as attach the relevant investigations
chronologically |
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Family History:
What is the family history of serious illness?
(Ex: hypertension, diabetes, heart problems, cancer, joint
problems, asthma, chronic skin diseases) If you have lost any
parent or family member, what was the cause of death? This above
history includes your brothers, sisters, parents, grandparents
and uncles and aunts on your father's and mother's side. Your
first cousins may also be included. |
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General
Symptoms
Thermal
State: Do you feel more hot or more cold? |
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Which types of
weather make you comfortable or uncomfortable? Are there any
types of weather that aggravate your symptoms? |
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Do you prefer
having a fan or draft from a window, or do these bother you? |
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Do you prefer
indoor or outdoor air? |
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What sort of
covering do you use throughout the year? |
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Do you prefer a
hot/warm or cold bath
throughout the year? |
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Perspiration
Do you
perspire a lot? |
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Which part(s) of
the body perspire most?
(eg. palms, soles of feet, head, face, upper lip, underarms,
back, etc. |
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Does the
perspiration have any smell? what type? |
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Does it stain the clothes, which is difficult to wash off? |
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Thirst
Do you
feel thirsty? How much water do
you drink per day? Do you tend to sip
or gulp liquids? Do you prefer it
cold or warm? How much do you drink at a time? |
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Food Cravings
How is your appetite |
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What are the food
items that you enjoy most? |
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What taste in food
do you prefer? |
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Do you prefer non-veg
food or vegetables? If non-veg, do you prefer meat, fish or
chicken? |
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Do you like milk
and eggs? |
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Do you like
sweets? Which type? |
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Do you feel like
eating indigestible things like Chalk, mud etc?
(This question pertains to ones own personal choice in taste
from childhood and does not refer to a diet that one has
adopted.) |
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Food aversions
What are the food items that you dislike the most? |
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What taste in food
do you avoid as you do not like the taste? |
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Tongue:
Look in the mirror and observe your tongue. Does it look pink
or pale or red? |
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is it dry or
moist? |
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Does it have a
coating? |
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If yes which part
of the tongue is coated? |
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What colour is the
coating? |
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Bowel:
Do you have any
problem with stool?
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Are you regular?
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If you have
constipation, since how long? |
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Is the stool hard
or soft? |
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Do you have a
normal urge or is it poor causing you to force? |
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Bladder:
Do
you have any difficulty with urination? |
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Any past or
current history of urinary tract infections? |
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Do you get up at
night? |
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How often?
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Sleep:
Do you sleep well? |
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If not describe
the problem in detail. |
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Do you have a
preferred position for sleeping? |
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Male Genital
System:
Please list any problems related to sexual anatomy and function,
eg., impotence, decreased desire, diseases, hydrocele,
surgeries, etc. |
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Female History:
Menstrual History: When was your first menstrual period? Do you have
regular cycles? Is the flow
scanty/moderate/heavy? Do you suffer from
any pain, backache, white discharge etc. before/during/after
menses? |
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Obstetric History:
How many children have you had? Were they normal
deliveries? Did you have any
miscarriages or abortions? |
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Mind Symptoms
(This part pertains to your personality and nature). Describe
your opinion of yourself, and if necessary get a family member
to help you |
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Detail your
immediate family, ie., what is your position in the family
(father/mother/child)? With whom do you live? |
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How many siblings
do you have and among your brothers and sisters, at what
position are you? Eg. Eldest, middle, youngest. |
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What is your
educational background? What circumstances caused you to stop,
or allowed you to continue? |
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How would you
describe your personality? |
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Please provide a
general description of your personality. |
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Compare yourself
to another brother, sister or friend. In what ways do your
personalities differ? |
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What do you enjoy
doing in your free time? (hobbies, studying, games, outings,
travel, dancing, etc.) |
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What are your
highest priorities in life? What makes these priorities
important for you? |
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Give examples of
past or current situations that are or have been especially
stressful. What has been your response to these situations?
How have those situations shaped you? |
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Describe your
relationship with others, eg., your immediate family, extended
family, friends or colleagues. What observations about your
behavior do you find others making? . |
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What things or
situations can make you uncomfortable or possibly fearful? (eg.,
certain animals, people, robbers, being alone, water, narrow
places, heights, flying, accidents, dark, death, disease, sudden
noises, thunderstorms, the future, unknown, performance, etc?) |
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Some people keep
their home or work space very neat and orderly, and others have
piles but may also know where everything is. What is your
tendency? |
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What hurts have
you endured in the past, and what emotions do you feel when
thinking about those hurts? |
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How would you
describe your confidence level? How do you feel about taking on
new projects or enterprises? |
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What aspects of
your nature are you unhappy about, and feel you need to change?
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Is there any
present situation, domestic, personal, economical or social
worrying you? Please give some detail. |
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What
emotions--anxiety, fear, anger, grief, etc., are especially
troubling for you? |
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Describe
situations which have made you feel doubtful or suspicious. |
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How are you
affected by exercise? |
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Describe
situations which have made you feel jealousy or envy. |
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When upset, some
people look to others for support, while others tend to keep the
problem private and don't look for consolation. Where are you
in that range of response? |
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What situations
have made you feel sad or depressed? |
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In what areas of
the body do you experience emotions, eg., neck/shoulder tension,
tightening of the throat, stomach upset, etc.? |
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What situations
have made you angry? Some people anger easily and forgive
quickly, others get angry slowly and forgive slowly. How would
you describe yourself? |
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What else can you
add to the above? What points do you feel are most important
for someone to understand who you are? |
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Have you had any
childhood experiences that have had a deep impact on you? Please
explain. |
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Have you had
Psychotherapy, Counseling, Religious Experiences or Healing
therapy before? How has this changed your attitudes or helped
you? |
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Dreams:
Please enumerate the type of dreams you get, especially if
they've left a strong impression or if they're recurrent. Even
if you don't remember your dreams, try to think about any
particularly strong or recurrent dreams you've experienced at
any time of your life. If the dream or dreams was/were
particularly significant for you, please describe in detail.
(For example, do you dream of family, known people, unknown
people, ghosts, animals, flying, falling, water, jungles, God,
snakes, etc?) |
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