Name            Age   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 72 73 74 75 76 77 78 78 79 80 81 82 83 84 85 86 87 88 89 90   Sex male Female    E.Mail

Occupation

Pre-History & Treatment

Chief Complaints

Past History                                                                                                                                  

Similar Trouble    YES NO Typhoid      YES NO             Malaria    YES NO              Influenza   YES NO

Tuberculosis         YES NO Dysentery    YES NO            Jaundice  YES NO            Pheumonia YES NO

Pleurisy                YES NO V.D             YES NO            Worms    YES NO                Allergy   YES NO

Skin Disease        YES NO Vaccination   YES NO                 Gout    YES NO       Masturbation YES NO

Infectious Disease YES NO Operation    YES NO Blood Transfusion YES NO Bleeding Tendency YES NO

        Previous Treatment                                                              Relevant History

FAMILY HISTORY

Similar Trouble Family Members 

Father      Mother       Brothers       Sisters     Wife/Husband           Children Sn/Dr                                        

   Relevant History

PERSONAL HISTORY

APPETITE Normal Medium Large THIRST Normal Medium Large Sleep Normal Disturbed Increased Loss of Refreshes Does not Refresh BOWEL Regular Constipation LooseStool

Sweet     Desire Aversion   Spicy Desire Aversion Sour Desire Aversion Bitter Desire Aversion Warm Desire Aversion

Cold       Desire Aversion    Salt   Desire Aversion Meat Desire Aversion Meat Desire Aversion      Fish Desire Aversion

Eggs       Desire Aversion    Milk Desire Aversion Juicy Fruits Desire Aversion         Indigestible things Desire Aversion

ADDICTION:   Alcohol              Tea             Coffee             Tobacco                 Drugs

DREAMS    Menses                                   

MENTALS SEXUAL FUNCTIONS

URINE     

PHYSICAL EXAMINATION

REPORTS ON INVESTIGATIONS                                                        

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