On-line Treatment

General Information
Name
Age years
Sex   Male Female
Address  
Telephone  
Email  
Religion  
   
About your Family & Hereditary
Father Mother
Occupation  Occupation
Disease (if any)  Disease (if any)
Brother's & Sister's
No. of Brothers  No. of Sisters
Disease (if any)  Disease (if any)
Any major disease in Maternal/Paternal side
Married at age of
About your Spouse
Occupation
Disease (if any)
Children  
No. of Son
Disease (if any)
No. of Daughter
Disease (if any)
History of any failure / disappointments, grief, reverse of fortune, loss of money, ambitions, fright (specify)
History of vaccinations
 
Your mind, intellect, will, emotion & consciousness
Your own observation about mind
History of any grief in the past
Your Memory (If forgetfulness then specify for what)
Your anger
Your fear of what (eg: ghosts, snakes etc.)
Anxiety (of what)
Thoughts
Weeping
Religious
Spending of money
Your Likings
   
Hobbies
Habits  
   (eg. Biting nails, tearing paper etc)
Any Addiction  
Colour  
(specify the colour you like most)
Dislike to colours  
(specify the colour you dislike)
Social liking  
Consolation  
Delusion  
Liking of cleanliness  
Any other observation  
   
Physical
Vertigo  
Head  
    (pain, dandruff, lice, etc.)
Eye  
Ear  
Nose  
Face  
Taste  
Salivation  
Teeth  
Throat  
Stomach  
Appetite  
Liking of which food  
Aversion to which food  
Stool (color, odor, mucus present or not, hardness etc)  
Flatulence (whether flatus passes freely or is it obstructed or any other complains)
Urine (color, any complains like burning or any discharge etc)  
Sleep    
Position  
Covers  
Dream (if any)  
Perspiration    
Parts of body  
    (which part, Odor, any staining on cloths when it dries up)
Bath  
Season    
Liking  
Dislike  
     
Sexual Complains of Male (if any)  
     
Sexual Complains of Female (if any)  
Menses Interval  
Duration  
Colour  
Other discharges  
     
Medical treatment taken  
     
Medical Reports  
 
I agree the Term & Conditions