|CASE REFERENCE NO:|
|FATHER’S / MOTHER’S NAME:|
|PRESENT WT. & HT:|
|PROFESSION / OCCUPATION:|
|PRESENT COMPLAINTS (MAIN COMPLAINTS):|
|ORIGIN OR CAUSE OF EACH COMPLAINT:|
|(PAST HISTORY (PREVIOUS DISEASES AND THEIR TREATMENT)|
|FAMILY HISTORY (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 etc:|
|Gonorrhoea / Syphilis or STD:|
|Psychiatric & Mental Disorders:|
|Anxiety Neurosis / Depression:|
|Any other sickness not mentioned above:|
|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 eating?
|Can you remain hungry for hours on end without food? Do you get irritable with hunger?|
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 time?|
|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 of winter?|
|Would you like your cup of tea or coffee piping hot? Or just normal warm?|
|How many cups of tea / coffee do you generally drink in a day?|
|Do you have any aversion to any drinks?|
|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, Cloudy, etc.|
|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, Mental 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 bowel evacuation?|
|How many times do you move the bowels? When?|
|Consistency:||whether Well formed Semi-formed Very hard Loose?|
|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 eating?|
|Any pain, burning, bleeding with stool?|
|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?|
Any difficulty 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 pregnancy?|
|Did you have normal deliveries?|
|Age of appearance of first period (Menarche)|
|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 menses?|
|Any heaviness or pain in breasts before menses? Any nodules in the breast?|
|Age of menopause|
|Any associated complaints at the time of menopause e.g. Hot flushes, Palpitation, Anxiety, Depression, etc.|
|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?|
Any particular 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?|
Any particular 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.)
Any itching or discoloration associated with it?
Any factors 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? Its details:|
|Any complaints or abnormality of the nails or skin around the nails?|
|Any complaints of hair falling, early graying, dandruff, thinning, etc.?|
|Any warts, moles, birth marks on the body?|
|Does your skin heal normally after an injury or takes very long to heal?|
|Any tendency to form excessive scar tissue (Keloids)?|
|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, etc.
Do you get startled easily by sudden noises, telephone bells, banging of doors, etc.
Impatient or hurried and hasty
Do you eat hurriedly and there is always a sense of hurry?
|Offended easily (cannot take any criticism)|
|Are you critical of others, always finding faults|
|Irritable, quarrelsome, violent, etc.|
|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 easily?|
|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?
If someone 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 around you?
Any imaginary 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, punctuality, etc?
Are you a perfectionist by nature, being meticulous, fastidious and even finicky?
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 you, etc.
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 of Therapeutics|
|X-RAY, CT-SCANS, MRI, others|
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