History Form for Non - Indian Patient

It is advisable that first you download the form, fill it offline and then mail it.
Personal Information
Name:

Address:

City:
State:
Pin Code:
Education:
Phone No.:
Fax No.:
Email ID:
Website:
Birthplace:
Date of Birth:

Age: yrs.
Birth Time: 
Weight: kg.
Occupation:
Occupation of Father / Husband / Partner
Occupation:
How do you feel concerning your problem
  Better Worse
At which time of the day / year
Which taste is pleasant or unpleasant
What effect have the different tastes?
Effects of season-weather-climate?
Effects of actions or rest / sleep
Present Health problems and symptoms
Any prior treatment taken for diseases or surgeries
Modern MedicineAyurvedicNaturopathyHomeopathyAcupuncture
If other; then please specify details.
Hereditary diseases
P - Parental; M - Maternal; S - Self
Blood Pressure Diabetes Leucoderma Short Height Heart Diseases
P M S P M S P M S P M S P M S
Father
Mother
Uncles
Aunts
Grandmother
Grandfather  
Sons
Daughters
Breathing problem Specs Eczema Cancer Others
P M S P M S P M S P M S P M S
Father
Mother
Uncles
Aunts
Grandmother
Grandfather
Sons
Daughters
Daily Regimen
Time you wake up :
Exercise  / Sports : if yes then details :
Time of taking Bath: How many times a day ?
Water : When:

Hobbies
Watching TV, Hours per day? Reading Books, Hours per day ?
Playing games, Hours per day ?

Music, Hours per day?

Other, How many  Hours per day ?

Involvements
In the work , In the homely atmosphere , In hobbies .

Your Family & Work environment: 
Family Atmosphere :
Pleasant, Distrustful, Jealous, Hatred, Tense, Friendly, Co-operative 
Office Atmosphere: 
Pleasant, Distrustful, Jealous, Hatred, Tense, Friendly, Co-operative 
Time of Work:
 Nature of work: 
Sitting, Intellectual, Hectic, Mental Tension, Air conditioned, Hot Atmosphere,   Shift Duty, Computer Work, 
Tours & Travels if yes, then How many days per month?
Driving: Two Wheeler, Four Wheeler km per day.

Drink you take
How many times   How many times
  None 1 to 2 3 to 4 5 +   None 1 to 2 3 to 4 5 +
Tea Milk
Coco Chocolate
Coffee Cold Coffee
Cold Drinks Other

About your food and timings 
Do you feel hunger?  Timings of taking food:
You take food: hunger. While taking food:
Timings of Breakfast: Time for completion:
Timings of lunch:       Time for completion:
Timings of Dinner:     Time for completion:

Main Items of Food
Please specify the food items & their quantity (e.g. how many times in a month and what quantity in terms of spoons, plates)  For the seasonal items specify the seasonal consumption.
Time:  A: None, B: Every day, C: Once in a week, D: Twice in a week, E: Once in 15 days, F: Once in a month
Quantity (No./ Spoons / Plates):  G : None, H: 1 to 2, I: 3 and above
Item How many Times Quantity Item How many Times Quantity
A B C D E F G H I A B C D E F G H I
Rice  Noodles
Pulses Grains Cornflakes
Yogurt Ice-creams
Sauce Deserts
Chocolates Puddings
Pineapple Banana
Apple Pomegranate
Peach Orange
Paw Paw Melon cantaloupe
Water melon Melon honeydew
Berries Cherries
Other sour items Other sour fruits
Donuts Chili / Mirch

Bread Spread 
a. Sauce : 1. Tomato , 2. Soya , 3.Chilli , 4.Other
b. Cheese , Variety
c. Butter: 1. Salted , 2. Unsalted , 3. Soya , 4. Peanut , 5. Other
d. Jam: 1. Pineapple , 2. Mango, 3. Strawberry , 4. Appricot , 5. Apple-raspberry , 6. Dark Plum , 7. Creamed Honey , 8. Mix Fruit , 9. Other
e. Vegemite : 

Vegetables
Raw Cooked
Cauli Flower Broccoli
Lady's Finger Spinach
Capsicum Yellow Chilly
Potatoes Tomatoes

Cereals ( Sprouted: Yes, No / Unsprouted: Yes, No )
Aconite leaved kidney beans (Mataki) Chick Pea (Chole)
Green Peas Horse Gram
Moonga Other 

Non Vegetarian

Chicken Beef / Pork
Goat Meat Red Meat
Fish Egg
Sardines Other

Salads
Cucumber Radish
Tomato Beet
Lettuce Onion
Carrot Other

Virudhanna (Unwholesome Combinations)

Banana + Milk

 Milk + Rice + Salt

Fruit Salad

 Yogurt+Milk+ Rice

Milk Shakes

 Butter milk + Milk + Rice
Water before/after Tea Khichadi (Dal + Rice) + Milk
Milk + Fishes Toast/Salted Biscuits + Tea

Stale Food Overnight Kept
Rice Bread
Meat/Fish/Pork Other

Usage of Freeze / Refrigerator for Putting
Raw Food Prepared food
Bakery Items Pastries
For Vegetables Ice-cream/ Milk/ Fruits

Cooking Media (Sneh Madhyam)
Peanuts Oil Olive Oil
Sesame Oil Refined Sunflower
Almond Oil  Other

Bakery Items
White Bread Whole meal Bread
Brown Bread Fruit Bread
Food grain Bread Berger
Toast Biscuits
Cake Veg Sandwich
Toast Sandwich Nonveg Sandwich
Pizza Other

Water
  How many Glasses   How many Glasses
  0 to 2 3 to 8 8 +   0 to 2 3 to 8 8 +
After wake up After Meal
During Meals At other times
Before sleep Total Quantity

Natural Instincts
Please note that for multiple selections you have to select the choices after pressing Ctrl key.

Stools
   Times / day Consistency:
Suppress Natural Urges: Yes, No    Try to do it forcefully without urge: Yes, No

Complaints:

Other:  

Urination

 During Day:  Times During Night:  Times.

Color

 Complaints

Sweat
Complaints More to
More odor ? Yes, No Leaving stains over cloth? Yes , No

Menses

Beginning at  years, Consistency of Menstrual Fluid :
Cycle of       Bleeding :        Color :
Smell: Yes, No  Complaints:
Any Miscarriages Yes, No, If yes then Number ,  Abortions ,  MTPs
Menopause: At the age of years  

Marital Life
Marital Status: Married : Yes, No    Unmarried:  Yes, No  
  Single ,     With Partner ,    LAT Relation ,  Divorced ,      Widow
Sexual intercourse:  
Complaints:  Masturbation:
Family planning using :  
Children: Sons,  How many? Daughters, How many?

About Sleep
At night:         Nature:
If sleep disturbed then can sleep again ?
Sleep during day ? If yes thenHours,Meal
Dreams:
Special Dreams: 
Other complaints during sleep: Pressing teeth and lips over each other , Talking , Walking .

About Eyes

Watch TV:  Hours Reading: Hours

How do you react?
Generally:    Reaction Answer: 
Speed of talking: Make decision:

Describe your psychology
1. Any psychological shock before onset of the disease upto one year,  If  yes, then  its  form  and its Severity 
2. Tension, Worry, fear before onset of the disease upto one year etc. happening : ?, If yes, then its nature and its period and its severity
3. Temperaments: Other:         
4.What do you think about your life
5. If unhappy / unsatisfied , in what respect
    and / or regarding
6. The reasons that you feel of your unhappiness or dissatisfaction
7. Have you taken any measures to make yourself happy / satisfied ?
    If yes : What is the current position
8. Do you constantly feel that you have been disappointed / neglected / tortured / suppressed?
9. Are you constantly afraid of your work / any condition / disease / any other factor ?
10. Do you hate somebody or you being hated by somebody for a long time ? If yes then reason behind it and measures taken to get rid of hatred.
11. Are you capable of adjusting against your mind ?Yes, No, If Yes then how much pain / tension you get after such an adjustment ? Select Severity1- low ..... 5- highest      
12. Do you often compare yourself with others, in financial, family, social status etc. If yes then does it lead to

ADDICTIONS 
Please specify the time & their quantity (e.g. how many times in a month and what quantity in terms of pegs, no., spoons)  
Time:  A: None, B: Every day, C: Once in a week, D: Twice in a week, E: Once in 15 days, F: Once in a month
Quantity (No./ Spoons / Pegs):  G : None, H: 1 to 2, I: 3 and above

 Food & Drinks
Tea Coffee
Chocolates Other
Hard Drink

Red Wine

White Wine
Whisky Rum
Champagne  Other  .

Drugs
Heroin Marijuana
LSD Ecstasy

Crack (Max)

 Other

Cigarette

Filtered

Unfiltered
General Addictions

Please specify the frequency of following:

A: None, B: Every day, C: Once in a week, D: Twice in a week, E: Once in 15 days, F: Once in a month
Horse Racing Lottery
Sex Other

 The form is strictly confidential. We welcome your suggestions regarding this questionnaire. We probably have covered each and every aspect of your life style. Pl. feel free for any other information that you will like to share with us.

Back Home