HealingHub - Adult-Form

Medical History

How is your appetite ?:

What happens when you are hungry for long ? :

Similarly dislikes & any food which causes problems ?:

What are your likings in food ?:

How is your thirst for water ? :

Bowels / Stools -- Do you have any tendency for constipations or loose motions, are they fine ? :

Sweat / Perpiration Do you sweat when you exert ot otherwise, area where you sweat, do you sweat on your palms & soles? :

Does it smell bad ? :

yes

Does the sweat leave stains on the clothes ? :

Is your urination fine ? :

(For Female Patients) Menstrual cycle—At what interval,regular, painful, any symptoms before menses, history of childbirth, abortions, miscarriage :

How is your sleep? Position of sleeping:

Dreams which you see often in sleep :

Thermally - How does your body react to heat or cold, can you tolerate heat more or cold more ?:

How do you feel in sun? :

Mind -- Most important-- Please answer freely, frankly & Completely , please do not hold anything back be-open & forthright. Take help to answer if you find difficulty in answering a question or let me know if you do not understand the question.

Describe your basic nature :

Are you an angry person? What makes you angry and how do you express it? :

Let me know about your family structure-- Who all are there & How is your relation to each brothers ,sister, mother & father ? :

Are you anxious (EG Exams, Facing Teachers, Pending Wark, Projects, Public Speaking) ?About what matters? Any physical symptoms when you are anxious ? :

Are you fearful about anything? (example darkness , Alone, Disease, Robbers, Future, High places, Rides, Water etc, ) :

Are you active or lazy by nature? Do you things actively on the 1st day or will do under pressure? :

How is your work life. Explain about it. Satisfaction in work, relation with colleagues & boss?:

Emotionally how are you?/ Expressive or unexpressive , Whom would you say or confide in? text :

Are you jealous or possessive for anything ? Sharing things or close people? Kindly explain :

In what matters would you be impatient, Hurried? :

Are you friendly or reserved? Do you prefer company or being alone? :

Do you remember old hurts causes by others for long ? How is your behaviour towards them or any negative thoughts in your heart :

How is your confidence generally?

How is your decision making ? Do you takelong time ? Do you ask people for opinions? :

Are you organized in keeping your things or unorganized ? :

How fussy are you about cleanliness? :

Do you weep easily? In what matters :

Is there anything in life that had permanently damaged you or scarred you? Kindly explain about it. :

How was your childhood ? Describe your nature in childhood & What is the difference now ? :

What are your strengths & Weaknesses in your nature? :

In your opinion what aspects of your mind,Nature is not agreeable to you ?Inspite of awareness are you unable to change them ? :

What has caused sadness to you in life & Very happy moments/joyous moments in life ? :

Are you worried Or unhappy about any CURRENT Personal, Domestic, Social ,Or Any other situation. Please describe if any. :

What activities, Hobbies do you like? Are you passionate about anything? similarly dislikes ? :

Adult Case

Kindly fill the form carefully, each question has a relevance!

Personal Information

Medical History