Patient Confidential Record

Patient Diseases

Personal History


b) How is your Digestion?

Any complaints after eating for example:

  • Fullness of abdomen, Gas formation or Diarrhea
  • Can you remain hungry for hours on end without?
  • Does any item of food cause any discomfort e.g. acidity, headache, flatulence etc.
  • Do you feel bloated, full and heavy after eating

(c) Thirst :

  • How is your thirst?
  • How much water do you take at a time?
  • How many times Drink Water per day?
  • What you prefer:


  • How you pass stool
  • Do you have:


  • Urine Frequency, day and night?
  • Any burning during urination/difficulty in passage of urine/ smell (odour) in the urine.
  • Is the urine very urgent and you must rush immediately?



  • Any sexual disturbances?
  • Excessive desire or aversion to sex?
  • Disability of performance, premature ejaculation etc.?
  • Night Fall?
  • Any H/O Sexual abuse, excessive masturbation etc.?
  • Any problem or complaints after intercourse?
  • Any Mental Depression at the Time or Before Sex?


  • Age of, appearance of first period (Menarche)?
  • Excessive desire or aversion to sex?
  • What is the duration of your period and how many days cycle
  • How is the menstrual flow?
  • Any Complaints associated with, before or after menses?
  • Any heaviness or pain in breasts before menses?
  • Any nodules in the breast or any other pre-menstrual symptoms?
  • Do you experience any sexual disturbances?
  • Desire /aversion to coitus?
  • Any leucorrhoea discharge?
  • Any Itching, burning or discomfort associated?)
  • Any sense, of weight or bearing down at the time of menses?


  • How many times have you been pregnant?
  • How many children do you have and their age?
  • Did you have smooth pregnancies?
  • Did you take any medication during pregnancy?
  • Did you have normal deliveries?


  • Age of menopause?
  • associated complaints at time of menopause?


  • Do you perspire a lot?
  • Any particular part of the body, that you perspire more on?
  • Any strong/offensive odor associated (e.g. sour etc.) with the sweat?
  • Does the perspiration stain the clothes?


  • Do you sleep well?
  • Any particular posture in which you sleep lying
  • Do you feel refreshed after sleep?
  • Do you dream while sleeping?
  • Any particular dream that is recalled and often repeated
  • Does any of your complaints get worse or better before, during or after sleep?


  • Any skin problem that you have had earlier?
  • Any itching, discoloration associated with it?
  • Any factors noticed which worsen the skin problem?
  • Any treatment taken for it?
  • Any complaint or abnormality of Nails or skin around it?
  • Any complaint of Hair falling, early greying, dandruff, thinning etc.?
  • Any warts, moles birth marks on the body?


  • Do you feel better in:-
  • Do you feel better in-
  • Any particular item of food/drinks which adversely affect you (or make you sick)
  • Do you feel better in
  • Do you feel
  • Do you feel
  • Do you feel better in sun exposure?
  • Do you feel better in
  • Do you feel better in
  • Do you feel better in Clothing/ covering?


Give in detail if any of your relatives (say Parents, Grandparents, Uncle & Aunty) are suffering or have suffered from the following.

List of diseases:

  • Allergies
  • Arthritis
  • Cancer/Malignancy
  • Diabetes Mellitus
  • Hypertension
  • Heart trouble
  • Heart trouble
  • uberculosis (Pleurisy)
  • Gonorrhea / Syphilis or STD
  • Psychiatric & Mental Disorder
  • Anxiety Neurosis / Depression
  • Any other sickness not mentioned above?
Live help!