Medical Questionnaire

Please fill in a detailed way for the medical team to assess the possibility of treatments.
A detailed report will also make the personal medical discussion more productive on the day of arrival.
Medical Details will be confidential with the medical team.
Old patients shall also fill in the current details however all your old records are available

Name

Age

Gender

Place of Residence

Chief Complaints

Complaint

Since: years/ months/weeks/days

Allopathic Diagnosis In Your Condition (if any)

History of your present complaints

Past Illnesses

Personal Informations

Diet

Are you Vegetarian or a Non vegetarian?

Vegetarian

Non vegetarian

How is your Appettite?

How is your Sleep?

Do you have day sleeping habit?

Addictions/Habits if any

Do you have Bowel evacuations Every day?

Total Evacuations In a Day

Time of Evacuation

Special note (if any)

How is your Urination?

Special note (if any)

What is your Occupation?

What is your nature of Work?

List the Current Medications that you take ( allopathy ):

Name Of The Medicine

Method Of Intake

Suggested For

Medicine

Write either the generic name or Brand name with mg

The way in which it is taken. Example - one tablet twice daily after food

Medical conditions for which it is suggested

Treatment History ( Information about various treatments underwent for the illnesses ):

Treatment History (Information about various treatments underwent for the illnesses):

Name Of The Treatmets

Underwent During

Special note (if any)

Gynaecological History:

Age Of Menarche

Age of Menaupoause

Menstrual Cycle

Bleeding

No of Days of Bleeding

Inter Menstrual Period

Date of last bleeding (LMP)

Other Information Which Might Be Helpful

Essential Lab Investigation Values

Please bring all the old medical records when you come.

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