Address with telephone number
Chief complaints with the following
How it starts? gradually or suddenly?
Where exactly the complaint is?
What is the exact sensation? Eg, pain,numbness, twiching, burning etc
What are the factors that worsen or improve the complaints? Eg, rest, movement, hot, cold,pressure,day,night,morning,noon,evening etc
Describe the associative complaint(s), if any
Past history of similar diseases or any other diseases with treatment history.
Family history of similar disease or any other diseases like diabetes, hypertension, thyroid problems, cancer etc
Describe the following
Appetite: increased or decreased, regular or irregular diet habits.
Thirst: increased or decreased, total intake per day, hot or cold, quantity at a time, with or without dryness of mouth.
Bowel habits: constipation, diarrhoea, bleeding, pain, burning.
Urine: frequency, quantity, colour, burning,specific odour.
Sweat: increased or decreased, single parts or whole body
Sleep: delayed, middle awakeness,early morning awakeness, disturbed, restless, unrefreshing, drowsy during the day.
Dreams: fearfull, repeated, disturbing, specific.
Menses: age at first menses, regular or irregular, early or delayed, date of last menses, nature of blood, profuse or scanty, painful or painless, history of white discharege if present
Likes and dislikes in food, in general.
Comfortable climate and reaction to temperature in general.
Level of irritability, anger, shyness, restlessness, suicidal tendency, depression, grief,emotion,disappointments etc
Laboratary Invetigation reports if any