Online Consultation

Name

Gender

MaleFemale

Height (cm)

weight(kg)

City

Phone

Email

Occupation

Details about your present Disease

If you have already seen a doctor, what diagnosis did they give you?

Mention the reports and brief treatment history

Is there anything else that might be helpful or relevant to your problem?

Physical Generals

Which weather you prefer most ?

Appetite

Thirst

Liking for specific taste/food

Urine

Stool

Perspiration

Sleep pattern, position during sleep

Speed (Walking, eating, working)

Sensitivity(To noise/ light/ sunlight/ high neck, ties/ narrow places/ closed rooms/ traveling in vehicles/ by air/ perfumes/ dust/ others)

Which you get relief from hot temp. or cold temp.

Mental Generals

Are You Anxious? About which Matter?

Are You Fearful? (Yes/No)

Are You Doubtful on suspicious? (Yes/No)

How would describe yourself as slow, medium, Fast ?

Are you revengeful?

Dou you become sucidal? in what manner

How is your memory

Are You early irritated ?

What make you angry ? Do you get violent ?

Do you like company ? or like to remain alone ? (Yes/No)

Your Nature as a child (Yes/No)

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