Professional Documents
Culture Documents
PRELIMINARY INFORMATION:
Name:
Date of Birth:
Postal Address:
Education:
Occupation & Designation:
Email ID:
Phone numbers:
CHIEF COMPLAINT:
What is your chief complaint for which you are seeking medicine?
What are the factors which make your problem worse or better?
What is the treatment you are taking currently for this complaint? (drugs & doses)
ASSOCIATED COMPLAINT(S):
In this section, please describe if you have any other complaints other than described above.
Describe about them in the same way as done in chief complaint.
Do you have a strong desire for any of the following food items?
alcohol __ coffee __ milk __ bread __ butter__ cheese__ meat __ eggs __ chocolate __
lemon__ pickles __ potato __ sweet foods __ ice cream __ cheese __ pastry __ salty food __
fatty food __ sour food __ bitter food __ fish __ oysters __ beer__ wine __ tea __ pop __ fruits
__ vegetables __ hot foods __ spicy foods __ cold foods __ room temperature foods __
What are the food items or tastes that you do not like at all?
Are there any foods that do not suit you, or aggravate your complaints?
How much do you sweat? On which body parts do you sweat the most?
How are your bowel habits? Do you suffer with either constipation / diarrhea ?
Do you get affected by any of the following? (if yes, describe the consequences)
Hot humid weather / Thunderstroms / Dark cloudy weather (lack of sunlight) / Snow
Are there any addictions (if yes, state quantity per day)?
alcohol __ cigarettes/tobacco __ sex __ coffee __ chocolate __ narcotics __ illegal drugs __
sedatives __ diet pills __
LIFE HISTORY:
Major highlights of your life since early childhood, if you think are relevant to your health issues.
1. How would you describe your disposition or temperament? (Chose whichever suits)
Affectionate / Meticulous / Fastidious / Shy / Indifferent / Impulsive / Messy /
Generous / Anxious / Destructive / Worrisome / Obsessively Compulsive / Docile /
Dominating / Mild & Timid / Moody / Jealous / Religious or Spiritual / Intellectual /
Leader / Follower / Discouraged / Absent-minded / Friendly / Pleasing everyone /
Sensitive to hurt / Reserved
repulsion for sex __ desire for attention ___ aversion to mental work __ aversion to company __
aversion to children __
Anything of your temperament that you would like to change, if possible – why:
Anything else about your mind, which is important for the doctor to know?
At what age did you get your first menses? Complaints experienced, if any -
How is your current menstrual cycle pattern (regular / irregular / absent / etc)?
PAST HISTORY:
Write down about diseases you have suffered in past (e.g.: Skin disease, T.B., typhoid, allergy,
pneumonia, surgery, etc.) – Have you been hospitalized for any reason so far ?
FAMILY HISTORY:
Diseases that your family members have suffered with (Diseases similar to yours, cancer, skin
diseases, tuberculosis, diabetes, heart disease, allergy, etc.)
PAST TREATMENT:
Please write what major medications/ medicines have you taken in the past.
ANYTHING ELSE?
Any other information that you would consider useful in your case evaluation.
RECENT PHOTO:
Please email your latest photograph, since the constitutional assessment is also done through
the physical features.