Your name

Age:

Gender:MaleFemale

Address(with pincode, state,country)

Contact Number

Your email

Religion and cast

Education and profession

Describe your chief complaint in details (onset, duration ,progress)
( when it started, How it increased and what factor worse or better your symptom better)

Associated symptom related to main disease

Past history(illness suffered and treatment taken)

Family history:(major illness in blood relations like TB, Asthma, Allergy ,Cancer ,diabetes or any other )

Habits(Tobacco, alcohol ,smoking or recreational drugs etc)

Appetite

Cravings(Things most liked in food pls make intensity +,+,+++)

Aversion(Food not liked by you/intolerance or allergy to food if any)

Thirst

Stool and Urine:

Perspiration:(sweat)

Thermals(which season does your complaint worse or better OR in which season you become uncomfortable or better?)

Dreams and sleep

Describe your personality:(mental make up nature etc)

Male sexual sphere

Female menstruation /Gynec/obst. history:

Sleep and dreams:(include fears, sleep pattern dreams which coming impact on you)

Additional information(remark or anything you specific mention about yourself)

Investigation/reports done/Treatment taken: