Medical History Form

Medical History Form for Adults


Kindly provide the information asked below. The information can be hand written on a separate sheet of paper or it can be typed (in the space provided below or separately in a word document) and mailed to tambolihomeopathyclinic@gmail.com


The information shared by you will be kept strictly confidential.



WRITE TO US

Gender:
Marital Status:
Food Habits:

Main Complaint and Associated complaints:

What is your main / associated complaint?


Since when are you suffering from the complaints?


Write in detail about how did each of the complaint start, how does it increase and what makes the complaint better. Also mention the treatment/s taken till now and the current ongoing treatment.


Kindly bring all investigations done so far at the time of the visit.


Daily Routine and Diet:

Kindly mention about your daily routine and diet.


Details of the family setup:

Please provide details of each member: name, age, occupation, your relationship with them.


Personal information:

Describe your emotional nature.



Detail your intellectual attainments and aspirations.



Write in detail about your relationship with family members, friends, work associates or anyone with who comes frequently in your contact.



Write in detail about any significant event/s which has had a impact on you.



Narrate in detail the stresses / tensions, if you have any.



Elaborately describe your responsibilities related to your work / family / friends and their fullfillment done till now.


Physical description:

Write a physical description of yourself Do you perspire?



If yes, Is it scanty, moderate or profuse?



Is it more on any particular part?



Describe the odour of the perspiration, if any Food: your likings and dislikings, any food that doesn't suit you


General environment:

Mention the weather that suits you



Does draft of air increase your complaints?



Do you suffer from motion sickness?



Do you suffer from sunstroke?


Sleep and dreams:

Describe whether you get sound or disturbed sleep. If your sleep is disturbed, mention the reason.



Do you talk, snore, grind your teeth in sleep?



Are you restless in your sleep?



Do you frequently get any dreams? Describe them.


Menstrual History:

Describe your menstrual cycle.



Do you suffer from any complaints before, during and after menses?


Obstretic History:

How was your mental state during the pregnancy/ies?



Did you have any medical issues during pregnancy and after delivery?


Sexual History:

Do you have complaints related to the sexual functioning?


Previous illness:

Share in detail about your previous illness, if any.


Family History:

Health details of your family members including grandparents, parents, brother, sisters, aunts,uncles.


verification image, type it in the box