Basic Information
Name* :
Email ID* :
Age* :
Gender* :
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Marital Status :
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Married
Unmarried
Address :
Occupation (Nature of Work) :
Education :
Present your complaint in detail
Main Complaint & Other Associated Troubles :
[?]
Previous Diseases & Drugs used :
Family History (Disease if any in Family) :
Personal information
Habits :
Salt :
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Like
Normal
Above Normal
Below Normal
Dislike
Disagree
Like but Disagree
Bitter :
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Normal
Above Normal
Below Normal
Dislike
Disagree
Like but Disagree
Sweet :
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Like
Normal
Above Normal
Below Normal
Dislike
Disagree
Like but Disagree
Spicy :
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Like
Normal
Above Normal
Below Normal
Dislike
Disagree
Like but Disagree
Sour :
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Like
Normal
Above Normal
Below Normal
Dislike
Disagree
Like but Disagree
Egg :
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Like
Normal
Above Normal
Below Normal
Dislike
Disagree
Like but Disagree
Fish :
Select
Like
Normal
Above Normal
Below Normal
Dislike
Disagree
Like but Disagree
Chicken :
Select
Like
Normal
Above Normal
Below Normal
Dislike
Disagree
Like but Disagree
Meat/Beaf :
Select
Like
Normal
Above Normal
Below Normal
Dislike
Disagree
Like but Disagree
Milk :
Select
Like
Normal
Above Normal
Below Normal
Dislike
Disagree
Like but Disagree
Vegetable :
Stool & Urine :
Sleep & Dreems :
Weather any other categories increases or decreases the disease :
[?]
Mental information
Are you anxious ? If yes about which matters ? :
Animals
People
Being Alone
Darkness
Death
Disease
Robbers
Sudden Noise
Thunder
Of the Future
Of something unknown
High Places
Timidity
Not Anxious
Are you fearful of anything such as :
Animals
People
Being Alone
Darkness
Death
Disease
Robbers
Sudden Noise
Thunder
Of the Future
Of something unknown
High Places
Timidity
Not Anxious
Are you doubtful or suspicious ? of what ? :
What are you jealous about ? of whom ? :
From what symptoms do you suffer when jealous ? :
in which matters are you impatient ? Hurried ? :
How long do you remember hurts camed to you b y others ? Offended Easily ? :
How much revengeful are you :
What are you proud of ? Does your pride get easily hurt ? (Egotism) :
Depressed / Brooding etc. ? :
Do you ever become suicidal ? When ? If so in what manner do you contemplate to end your life ? Even then are you afraid of dying ? :
When are you cheerful ? :
Are you sexual minded ? :
Any unwanted thougts any time ? What are they? :
Have you any imaginary sensations of fears ? :
Do you hear voices as that you are called or anything else in this line keeps on occurring in your mind unduly? :
How is your memory ? :
For what is poor ? e.g. Names, Places, Faces, what you have read, etc. ? :
Do you weep easily ? What makes you weep? :
How do you feel after weeping ? :
How do you feel if someone offers sympathy and consolation ? :
Are you easily irritated ? :
What makes you angry ? :
What bodily symptoms do you develop when angry ? e.g. trembling, sweating, etc. ? :
Do you like company ? Or like to remain alone ? :
How seriously are you affected by disorder and uncleanliness in your surrounding ? :
What are the greatest griefs that you have had in life ? :
What are the greatest joys that you have had in life ? :
What activities you deeply like ? Are there any matters which you deeply dislike ? :
In your opinion, which aspects of mind and moods are not agreeable to you. Inspite of your awareness and maturity, are you unable to change this aspect ? :
Give a clear cut picture of your situation in life and your relationship with each of your family members, friends and associates in work. How does the future look to you ? :
Other information
Other details (Give your lab report or scanning report) :
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