Case Record Form

Name*

Age*

Address

Email:*

Nationality:

Diagnosis:

Past history(any illness suffered in past and treatment taken):

Appetite:Vegetarian/Non-Vegetarian):

Intolerance to any food:

Preferences and likes/ dislikes to drinks (hot, cold, tea, beverages etc):

Urine

Sexual sphere:(male)

Sleep and dreams:(kind of sleep, any sleep disorders,dreams that have come frequently,have affected you a lot,had a deep impact on you):

Mind:(give as much details as possible)

Are you short tempered,irritable and conditions in which you get angry:

Fears and phobias of any kind:(how do you react in it):

Are you suspicious or doubting by nature?

Do you cry easily and what makes you cry?(any situations,memories etc)

How do you react to contradictions and oppositions:

Date

the topic of your message

Sex

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Contact Number:

Marital Status:

Occupation:

Present or chief complaint(onset, duration and progress in detail):

Family history (any kind of illness in family and relatives):

Likes / dislikes to any kind of food: (mention its intensity in grades of +, ++, +++):

Thirst:(how is the thirst, quantity and interval of water intake):

Stool and bowel movements:

The climatic and atmospheric changes and your reactions to them:

Female:(in regards menstrual cycle,pattern,regularity,pregnancy,menopause,other genital infections and disease):

Hobbies and interest:

Are you anxious by nature?

Reactions in anger:

Are you impatient and hurried?(in what matters):

Are you silent, reserved and introvert or extrovert and friendly:

Are you over concern about cleanliness, order, punctual, and a perfectionist: