FATHER’S / MOTHER’S
PRESENT WT. & HT:
PROFESSION / OCCUPATION:
COMPLAINTS (MAIN COMPLAINTS):
ORIGIN OR CAUSE OF EACH COMPLAINT:
(PREVIOUS DISEASES AND THEIR TREATMENT)
(If any of your blood-relatives,
i.e. parents, grandparents, siblings,
aunts and uncles, suffer or have suffered
in the past, from the following):
Cancer / Malignancy:
Coronary Artery Disease, Angina
Gonorrhoea / Syphilis or STD:
Psychiatric & Mental Disorders:
Anxiety Neurosis / Depression:
Any other sickness not mentioned
Kindly elaborate and
mention habits, addictions like alcohol,
smoking, tobacco etc.
Are you vegetarian or non-vegetarian:?
Do you consume eggs?
Craving For Foods:
Mention grades of preference +,
++ or +++.
For example if you love
sweets, mention + or ++ or +++
Do you add Extra salt in your food?:
Sour foods / pickles:
Seasoned and spicy:
Fried and fatty food:
Any other cravings in food?
Do you dislike sweet or salty or
any other specific food?
How is your Digestion?
Any complaints after eating?
Do you experience
Fullness of the abdomen, Gas formation
or Diarrhea after eating? Do you
feel bloated, full and heavy after
Can you remain hungry for hours
on end without food? Do you get irritable
Does any item
of food cause you discomfort, e.g.
Acidity, Headache, Flatulence, etc.
How is your thirst,
generally? Please mention the grade
of thirst? If you are very thirsty,
you may mention grades +, ++ or +++
How much water do you drink at a
How many times per day?
Your preference in drinks:
Please mention the degree of craving
+, ++ or +++
Would you prefer cold / chilled
water or drinks even in the height
Would you like your cup of tea or
coffee piping hot? Or just normal
How many cups of tea / coffee do
you generally drink in a day?
Do you have any aversion to any
State how you are affected
by or how you react to the following:
1. Cold in general, cold air, drafts,
cold winds, etc.
2. Do you like
to cover your head (or wear a cap)
when you go out in the cold or when
exposed to a draft of cold air?
3. Warmth in general, warmth of
bed or of room, external warmth like
hot fomentation, etc.
4. Weather: Dry, Cold wet, Rains,
6. Open fresh air
7. Near the sea / on mountains
8. Eating and Drinking (before,
during and after)
10. Any particular
item of food / drinks which adversely
affect you or make you sick
11. Closed, Crowded places, Elevators
/ Lifts, etc.
12. Exertion or Physical strain,
13. Lack of sleep
14. In what part of 24 hours do
you feel the best or the worst?
15. Do your troubles tend to occur
or become worse, periodically (e.g.
Daily or alternate days, every week,
yearly, during new or full moon etc.)
STOOL / BOWEL MOVEMENTS
Do you regularly have a satisfactory
How many times do you move the bowels?
whether Well formed
Color of stool:
Any straining required for passing
stools even though stools might not
be hard or constipated?
Any urgency for stools (e.g. Do
you have to run for stool first thing
in the morning or immediately after
Any pain, burning, bleeding
Piles / Fissure / Fistula?
Do you have
flatus (wind) when passing stool
and is the stool noisy and spluttering?
Frequency, day and night:
Any burning during urination?
Any smell (Odor) in the urine?
Any difficulty in passing urine?
in retaining urine? Do you have
any incontinence while coughing
or sneezing? Is the urine very urgent
and you must rush immediately or
it will escape?
Any associated complaints with urination?
Any complaints related to the reproductive
system? Please give details.
Any leucorrhoeal discharge? Itching,
burning or discomfort associated?
Any sense of ‘bearing down’
at the time of menses?
How many times have you been pregnant?
How many children do you have and
what age are they?
Did you have smooth pregnancies?
Did you take any medication during
Did you have normal deliveries?
Age of appearance of first period
How are the periods?
What is the duration of your period
and how many days cycle?
How is the flow? – (scanty,
heavy, clotted, any odor, color)
Any PMT (Pre-menstrual
tension)? Do you have any complaints
associated with, or before or after
your menses? E.g. Moods, Headache,
irritability, Anger, Weeping, Depression,
Diarrhea or Constipation
Any changes in your skin around
Any heaviness or pain in breasts
before menses? Any nodules in the
Age of menopause
Any associated complaints at the
time of menopause e.g. Hot flushes,
Palpitation, Anxiety, Depression,
Do you perspire a lot?
Any particular part of the body
that you perspire more on?
Any strong / offensive odor associated
(e.g. Sour smell) with your sweat?
Does your perspiration stain your
clothes or leave any salty deposits?
Do you sleep well?
posture in which you lie the most
when you sleep? E.g. Lying on the
sides (right or left), back or on
your abdomen, curled up, etc
Do you feel refreshed after sleep?
Do you dream while sleeping?
Do you sleep-walk, sleep-talk, or
grind your teeth in your sleep?
dream that is recalled and often
repeated? (E.g. frightening dreams
of falling from a height, or being
pursued by some men, or dead people
or relatives, etc.)
Do any of your
complaints get worse or better,
before, during or after sleep? E.g.
Cough or asthma attack that wakes
you up at night; migraine on waking
in the morning; hot flushes just
as you begin to fall asleep.
Any skin problems
that you have or had earlier? (E.g.
allergies, eczema, fungal infections,
pigmentations, acne, etc.)
or discoloration associated with
which worsen the skin problem? E.g.
Any food item, weather conditions,
or washing with warm or cold water.
Any treatment taken for the skin?
Any complaints or abnormality of
the nails or skin around the nails?
Any complaints of hair falling,
early graying, dandruff, thinning,
Any warts, moles, birth marks on
Does your skin heal normally after
an injury or takes very long to heal?
Any tendency to form excessive scar
Any tendency for wounds to suppurate
(form pus easily)?
(It is very important
to give as much details as possible
in this section of the Pro forma especially
in the case of Chronic Diseases)
Have you noticed
any marked changes in your mental
state lately? If so, describe it
in detail please.
Have you become or are-
Anxious / afraid
of anything, e.g. being alone, animals,
darkness, disease, thieves, robbers,
Do you get
startled easily by sudden noises,
telephone bells, banging of doors,
hurried and hasty
Do you eat hurriedly and there is
always a sense of hurry?
Offended easily (cannot take any
Are you critical of others, always
Irritable, quarrelsome, violent,
Depressed easily, sad, gloomy
Timid / Shy / Bashful
Jealous or Suspicious
Anxious, restless, nervous or excitable
Do you feel
very anxious and apprehensive before
examination, before stressful situations,
public engagements, etc.?
Are you silent, quiet, reserved
or talkative? Do you make friends
Are you very affectionate? Do you
demand love and warmth from others?
Do you cry easily? What makes you
cry (grief of others, music, kind
words of affection, etc.)?
Are you very
sympathetic in general and go out
of your way to help people in need?
Are you easily moved to tears at
the plight of others?
consoles you when you are upset,
does it help or does sympathy towards
you makes matters worse?
How do you stand and react to contradictions?
Are you an
authoritative person, always in
command and giving orders and expecting
them to be followed by everyone
fears or feelings? (e.g. That someone
might want to harm you or hurt you
and that people are against you)
How is your memory, power of concentration
and mental ability?
Do you feel
humiliated or hurt easily? Would
this give rise to any physical complaints?
Are you over conscientious about
details, cleanliness, tidiness,
Are you a perfectionist by nature,
being meticulous, fastidious and
What is the
greatest grief that you have felt
in life? Also what are the greatest
joys you have experienced in life?
Can you mentally
relax easily? For instance, can
you switch your mind off work, problems,
children, etc.? Do you enjoy vacations?
Can you totally relax when on a
holiday or do thoughts of work or
what is happening at home keep bothering
At work, with
colleagues, subordinates or your
boss or seniors, how do you equate
with them? Would reprimanding or
scolding from them upset you tremendously?
If so, how?
PREVIOUS TREATMENT TAKEN
Disease Medicine Prescribed System
X-RAY, CT-SCANS, MRI, others
customer hereby grants a Private
License to Biogetica to engage in
bioenergetic and/or nutritional
modalities with the customer. The
customer acknowledges that Biogetica
and its agents do not diagnose or
prescribe for medical or psychological
conditions nor claim to prevent,
treat, mitigate or cure such conditions.
Biogetica and its agents do not
provide diagnosis, care, treatment
or rehabilitation of individuals,
nor does Biogetica and its agents
apply medical, mental health or
human development principles, but
rather provides bioenergetic and
nutritional modalities that may
benefit. The customer gives Informed
Consent to the services that will
be provided. The customer hereby
releases the Biogetica and its agents
from all claims and liabilities
arising from the use or misuse of
spiritual, mental, bioenergetic
and/or nutritional modalities, indemnifying
and holding Biogetica and its agents
harmless from all claims and liabilities
therefrom whatsoever. Biogetica
and its agents reserve all rights.