Chief complaint:

 

History of present illness -

Onset - How did it start? Gradually or suddenly?

 

Location(s):

 

Intensity

Could you discomfort on a scale of 1 10

 

Nature of Pain/Type of pain - Please describe your pain/symptoms

 

 

Radiation - Is the pain fixed or does it travel

 

 

Aggravating and relieving factors i.e.what make it worse and what makes it better.

 

 

 

What have you tried? (chronological order)

 

 

 

 

Past history: Please give reasons and dates for any hospitalizations

 

 

Women only:

 

How many pregnancies did you have? Please include dates

How many live births did you have? Please include dates

When was your Last Menstrual Period?

 

Are you menopausal? If yes, skip to the next section

 

How many days did your period last?

 

Were there any clots? If so, please give amount and color and size

How many days between periods?

 

Allergies: Please list what you are allergic to, for how long and if they are under control. If they are under control, are they under control with meds (western or other) or lifestyle?

 

 

Medications and supplements: please list your medications include dosage and frequency

 

 

 

 

 

 

 

 

 

Family History:

 

Is there anyone in the family who has similar complaints?

 

If yes, how are they related to you?

 

 

When did their complaint start?

 

 

How are they now?

 

Are there any major illnesses that run in the family (cancer diabetes high blood pressure etc.)

 

 

 

 

Who?

 

 

 

 

 

 

What is the current condition?

 

 

 

Personal History

 

Some of these questions might bother you, if you feel uncomfortable answering them Please let me know

 

May I know your ethnic background?

 

 

What is your educational background?

 

 

What do you do for a living?

 

 

What is included in your diet?

 

 

How would you rate your diet?

 

 

Do you drink smoke or use any recreational drugs? If so How often per day, per week etc.

 

Have you quit drinking, smoking or using any recreational drugs? If so,

 

How long had you been smoking/drinking?

 

When was your last Drink/Cigarette

 

What drugs were you using?

 

How long

 

How frequently

 

Sleep:

What time do you get to sleep?

 

 

How many hours? Is it consistant?

 

 

How do you feel when you wake up?

 

Do you get hungry at regular times?

 

Do you eat at regular times?

 

 

Bladder - frequency, color, abnormality

 

 

Bowels - regular, color, consistency, difficulty

 

 

Do you have an aversion to wind or cold or heat?

 

Do you have any abnormal sweating?

 

 

Do you experience headaches or any other body aches?

 

 

Do you experience any discomfort in the chest and abdomen?

 

 

Do you have any ringing in the ears?

 

 

Please describe your social habits.

 

 

 

 

Please give your average working day daily routine:

 

 

Quality of sleep:

 

 

 

 

Arise from bed: (time, ease of awakening)

 

 

 

 

Morning routine: (include details of a typical breakfast)

 

 

 

 

 

Noon:

 

 

 

Afternoon:

 

 

 

Evening:

 

 

 

Retire: