First Name

Last Name

Email Address

Phone Number

Please write a brief account of your present problems and information about how long you have had them (in chronological order). (eg :"Difficulty in breathing started in --- after being out in the cold for--- days.")

Family History Going all the way back to paternal and maternal grandparents. (Allergies, skin problems, asthma, Alzheimer's, migraines, any other neurological disorders, heart problems, cancers, mental disorders, etc. For example, " Elder sister has/had eczema, paternal aunt died because of complications of heart disorders, maternal grandma had Alzheimer's," etc.

Childhood History (As far as you can remember) whether your delivery was normal or caesarian, whether there is a history of neonatal jaundice, measles, mumps, typhoid etc. Any effects of vaccinations like fevers, loose bowels, frequency of colds, running nose, coughs.

And also: Milestones of life (as far as you can recollect): teething, trying to sit up, walking, talking, etc. (on time, delayed, early).

History of broken bones, accidents, head injuries, dog/insect bites etc.

(a) How is your appetite?

(b) Is there a tendency to indulge in particular kinds of foods (eg: sweets, sour foods, salty foods, etc.)

(c) Are you allergic or sensitive to any foods?

(d) What kind of weather are you most comfortable in? (Summers, humid weather, winter)

(e) Are you particularly uncomfortable in any weather or climate?

(f) Do you sweat at all? If you do, where do you sweat noticeably? (Scalp, upper lip, under arms, back, chest, etc.) Under what circumstances? (While eating, under tension, when you physically exert yourself etc.)

(g) In general do you like being out in the open air or do you feel more comfortable in closed rooms?

h) Do you dream at all? If you do, do you remember them? What is the content? (eg: daily events, falling into space, running after a train, etc.)

(i) How is the quality of your sleep most of the time? (Rested and refreshed, feel tired most mornings etc.)

(j) How is your bowel habit? (Regular, constipated, diarrhea etc.) Is it modified by anxiety? By diet (eg. spicy food causes diarrhea)?

(k) How is your liquid intake? (Feel thirsty all the time, fairly normal etc.)

(m) How do you react to stress and tension? (Tend to be verbally expressive, tend to keep things to yourself and brood about them, etc.)

Additional Information(if any)