Name*

Sex

Age

Address*

Height

Weight

Complexion

Colour of Hair

History Of Presenting Illness (Since when are you facing these problems, details of these problems)

Past Illness

Causation
(If Any)

Family History

Habits -Alcohol, Tobocco, Drugs etc

Desires & Aversions (What do you like in eating and drinking)

Any special liking for

a) What makes your Complaints Worse

b) What makes your Complaints Better

Mental Symptoms

Previous Treatments
(Treatment you have already had in the past)

Laboratory Investigations

Evaluation of Symptom & Repertorisation (For Doctor Only)

Prescription (For Doctor)

Cheque /DD  No.

Date

Bank

Consultation fees