History of Vaccinations and Inoculations: Please mark the box if you have had the following vaccinations: If you have experienced allergies to any of the following, please mark the box Medications:
Please list the medications you are taking (prescription, over-the-counter, and supplements). Complete the column for dosage and mark the box for how often you are taking each medication. Attach additional pages if needed.
Medication Name: Dosage: Medication Name: Dosage: Medication Name: Dosage: Medication Name: Dosage: Medication Name: Dosage: How many? Occupation:
How many drinks do you have per week?
Glasses of Wine Cans of Beer Shots of Liquor Have you ever used recreational or IV drugs? Smoking/ Tobacco/Nicotine Use: Have you ever smoked or used tobacco/ nicotine products? Used for how many years: When did you quit? Cigarettes per day: Have you ever used vaping or e-liquid products? If you use these products, do you use: Used for how many years: When did you quit? Cartridges per day:
Which substances do you or have you used?
What types of devices do you or have you used? Are you sexual-minded? Any excessive indulgence in sex in past and present? Any effect on your health? How do you feel after sexual intercourse? Do you suffer from any sexual disturbance? Any habit like masturbation like masturbation in past as well as present? If yes, how often? Any homosexual inclination? Did you suffer from any sexually transmitted disease? Do you have increased or decreased for sex? What is the method you use for family planning(contraception) Any difficulty in erection? Unwanted erection? Weak erection? Menses: how are the periods; regular or irregular? At what age did you start? Was there any trouble then? Mention interval between two period? Mention number of days of flow? Is there any change in quantity, colour, smell or consistency? Are the stains difficult to wash? Have you noticed any variation in quality and quantity in flow of menses? How? When? Do you suffer in any way before, during or after the menses? (if yes, describe) What symptoms did you suffer during menopause? Do you feel internal parts coming down? Is there any white discharge? (if so, mention colour, consistency and smell of discharge) Do you pass gas from vagina? Any trouble with breasts? (if yes, describe) How is your appetite? When you are hungry? What happens if you remain hungry for a long time? How fast do you eat? How much thirst you have? Any particular time you are especially thirsty? Please select if you like/dislike the food or if the food disagrees. Do you have any problems regarding you stools? When and how many times a day you pass stools? When is it urgent? Do you have any problem about bowel movement? Do you have to strain for stool? Even if soft? Do you have belching or passing gas? Describe its character. How do you feel after passing gas up or down? Any problem about urine? Any strong smell? Like what? Do you have any trouble before, during and after passing urine? Any difficulty about the flow? Slow to start, interrupted, feeble, dribbling, etc.? Any involuntary urination? when? Sweat/Perspiration-Fever-Chill
How much do you sweat? Where and on what part do you sweat most? Do you perspire on the palms or soles? Is the sweat warm, cold, sticky, greasy, etc.? What is the smell like? Foul, pungent, sour, urinous, etc.? Any other symptoms after sweating? What colour does it stain on the clothes? Is the stain easy or difficult to wash? Do you catch cold often? Describe the symptoms, nature of discharge, etc.? Is there any difficulty in breathing? Is there any difficulty in your voice? Do you have experienced any sense of cold or heat in any part of your body at any particular time? Do you have cough? Is it more at any particular time? Vertigo-do you have giddiness? Faintness: do you ever feel fainted? Headache-do you get headaches? (if so, how often) Eyes and vision: Ears and sense of hearing: Nose and sense of smell: Face and facial expression: Mouth and sense of taste: About lips (cracked, peeling of skin, etc.) About teeth’s and gums: Throat (including tonsils, etc.) Any difficulty in swallowing? Do you have pain in your back, limbs, joints? Describe: If you have pains, do they shift? In what direction do they extend? Is there any abnormality, paralysis, numbness in any part of the body? Is there any trouble with skin: such as itching, eruptions, ulcers, warts, peeling, etc.? (describe) Any change in colour of the skin or spots of the body? Is there any complaint about nails and skin around? Is there any trouble with hair such as (falling, greying, dandruff, oily, poor or excessive growth, etc)? Do wounds heal slowly? Form keloid? Do wounds tend to form pus? Have you a tendency to bleed? Are your troubles only one sided? Which one? Or more on one side? Do they proceed from one to the other side? Or do they alternate or shift? Is there any trembling? When? Are there any senses of weakness? Where? When is it more or less? Is it in any particular part of the body? MIND
It is universally acknowledged that your mind has tremendous influence on your body. For giving proper medication it is absolutely necessary for us to understand your emotional and intellectual nature. We can thus treat you as a whole.
In order to understand you; we will be asking some certain questions.
Answer them freely, carefully and completely.
Are you anxious? Are you fearful of anything such as animals, people, being alone, death, robbers, sudden noises, thunder, of the future, high places, etc.? Are you doubtful or suspicious? Of what?? What are you jealous about? Of whom? From what symptoms do you suffer when jealous? In which matter you are impatient? How long do you remember hurts caused to you by others? How much revengeful are you? What are you proud of? Does your proud get easily hurt? 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? Any unwanted thoughts in your mind any time? What are they? Do you have any imaginary sensations or fears? Do you hear voices, or that you are called, or anything else in this line keeps on occurring in your mind unduly? How is your memory? For what is it poor? (e. G. Names, places, faces, etc.) Do you weep easily? What makes you weep? How do you feel after weeping? How do you feel if someone offers you sympathy and consolation? Are you easily irritated? What makes you angry? What bodily symptoms you develop when you are angry? (Trembling, sweating) Do you like company? Or like to remain alone? How much are you affected by uncleanliness in your surrounding? What are greatest griefs that you have gone through in your life? What are the greatest joys that you have had in life? What activities you deeply like? In your opinion, which aspects of your mind and moods are not agreeable to you? Inspite of your awareness and maturity, are you unable to change these aspects? Give a clearcut 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? When you are free, what thoughts come to your mind? Are you worried or unhappy over any personal, domestic, economic, social or any other condition? (If so, describe) If asked for 3 desires or wishes in life, what will you ask for? Describe your posture in sleep, on the back, side, abdomen, etc.? Are you able to sleep in any position? In which position you cannot sleep? Describe if anything is unusual about your sleep: (sleepy, sleeplessness, etc.) Do you have to uncover any parts?
Main complaints and other associated troubles: (and detailed history of the present illness. The onset and course with dates).
Origin of cause: can you track the origin of the present illness to any particular circumstance, accident, illness, or mental upset? Tick the types of dreams that you have If any other: (specify below)